Member Forms & Resources

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MEMBER FORMS & RESOURCES

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 form to allow your plan to withdraw your monthly plan premium payment from your checking or savings account on the 10th of each month.
Prescription Drug Forms
Locate prescription drug forms including mail order and reimbursement forms.
New Member
Medicare Transition of Care Form

In order to facilitate continuity of care for scheduled surgeries or planned procedures, or complex or chronic conditions for which you or your dependents are undergoing regular treatment, please complete the information on this form.


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.

Page Last Updated: 09/28/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

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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.