Member Forms

Medicare Member Designated Representative Form

Complete this form if you want someone to act on your behalf. To prevent unauthorized use, these forms are posted on our Secure Member Portal .

Appointment of Representative Form

You can name a relative, friend, advocate, doctor, or someone else to be your appointed authorized representative. This will give that person the right and ability to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and the person you want to act for you must sign and date a statement that gives this person legal permission to act as your authorized representative.

If you have any questions, please contact Customer Service at the phone number listed on the back of your ID card.

Prescription Drug Forms

Find various forms such as the coverage determination form and the prior authorization forms in this section of the site. 

Over-the-Counter Catalog Program

Over-the-Counter Catalog Program order form.  See your Evidence of Coverage for more information regarding the Over-the-Counter Catalog program benefits.

Advance Directive

Advance Directive Form.  This form can also be found in the new member kit that you were mailed when you first joined Advantra (HMO-POS).

Transition of Care Form

Transition of Care Form for new members.  If you did not fill out this form at the time of enrollment, please print, fill out, and return to Coventry.

Authorization Agreement for ACH Debit Form
Coming Soon

Complete this form to have your health plan premium deducted from your bank account each month.

Additional Plan Information

Dental Service Provider Directory

Coventry Dental Provider List.  Provider listing may change, so please visit www.cvtydental.com for the most up-to-date list of in-network dental providers.

BenefitsCheckup

Coventry Health Care has partnered with the National Council on Aging to provide our members with access to BenefitsCheckUp, a web-based tool that can help you determine if you may be eligible for programs that can assist with your expenses.