Member Forms

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 Member Services at the phone number listed on the back of your ID card.

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 .

Authorization Agreement for ACH Debit Form - Coming Soon

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

Dental/Vision Claim Form  

Prescription Drug Forms

Locate prescription drug forms including mail order and reimbursement forms.

Additional Information

Provider & Pharmacy Directory - Coming Soon

To get the most up-to-date information about Advantra® plan providers and pharmacies in your area, contact the Customer Service Department .