Additional Forms and Documents

Appointment of Representative Form

Our members can appoint a caregiver to act on their behalf. To do so, we must have written authorization signed by both the caregiver and the member.

A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Download an Appointment of Representative form. Once the form is filled out in its entirety fax it to the Customer Service at 1-877-598-9888.

Exception and Prior Authorization Forms

Print Part C Prior Authorization Form.

Learn more about Part D Coverage Determination and Exceptions

Print Part D Coverage Determination Form.

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