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 .

AdvantraOne Transportation Reimbursement Form

Only AdvantraOne members are eligible for this benefit. Reimbursement is not available for other family members or friends.  If you have any questions about the transportation reimbursement program, please contact the AdvantraOne Customer Service Department.

Additional Information

BenefitsCheckUp

Many seniors qualify for assistance that they are not receiving.  Go online today to find available programs.  Completing the BenefitsCheckUp questionnaire only takes a few minutes. It is available to you at no cost and your answers are always private.