Member Forms & Resources

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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.
Electronic Funds Transfer (EFT) Form
Use this authorization agreement form for ACH debit to allow your plan to withdraw your monthly plan premium payment from your checking or savings account on the 10th of each month.
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.
Prescription Drug Forms
Locate prescription drug forms including mail order and reimbursement forms. 


Reimbursement Forms

Member Medical Reimbursement Form
Return the completed form and applicable receipts to the address for your health plan listed in the attached document.
Part D Vaccine & Administration (Injection) Claim Form
This claim form is for reimbursement of covered Part D vaccines and their administration (injection). Please consult your Evidence of Coverage for specific coverage information.
Prescription Drug Claim Form
Request reimbursement for prescription drugs by completing this form.
Additional Information

New 2014 QIO Contact Information

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Page Last Updated: 03/18/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2014 Coventry Health Care

Coventry Health Care is a Coordinated Care plan with a Medicare contract. First Health Part D is a Medicare-approved Part D sponsor. Enrollment in our plans depends on contract renewal.