Forms and Documents

2021 Personal Medication List (PDP) English | español

2021 Personal Medication List (MAPD) English | español

2021 Personal Medication List (DSNP) English | español

2021 Online Coverage Determination Request Form

2021 Online Coverage Redetermination Request Form

2021 Mail-Order Physician New Prescription Fax Form

2021 Pharmacy Mail-Order Form

2021 Prescription Drug Claim Form

2021 Medicare Part B vs. Part D Form

2021 Authorization to Disclose Protected Health Information (PHI) Form

2021 CMS Appointment of Representative Form (PDP) 

2021 CMS Appointment of Representative Form (MAPD)

2021 CMS Appointment of Representative Form (DSNP)

2021 Notice of Privacy Practices

2021 Access Additional Privacy Forms

2021 Automated Premium Payment (ACH) Form (PDP)

2021 Automated Premium Payment (ACH) Form (MAPD)

2021 Automated Premium Payment (ACH) Form (DSNP)

2021 Prescription Drug Coverage Determination Request Form (PDP) English | español

2021 Prescription Drug Coverage Redetermination Request Form (PDP) English | español

2021 Prescription Drug Coverage Determination Request Form (PPO) English | español

2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español

2021 Prescription Drug Coverage Determination Request Form (HMO) English | español

2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español

2021 Prescription Drug Coverage Determination Request Form (DSNP) English | español

2021 Prescription Drug Coverage Redetermination Request Form (DSNP) English | español

2021 Prescription Drug Formulary Exception Physician Form

2021 Prescription Drug Tier Exception Physician Form

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.