Advantra Freedom (PFFS) - Employer Group Member Forms

Provider Outreach Form

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Complete this form if you would like an Advantra Freedom (PFFS) representative to contact your physician(s) on your behalf to explain how the plan works and to answer any questions your doctor's office may have.

Provider letter

Advantra Freedom (PFFS) - No Prescription Drug Coverage - click here

Advantra Freedom (PFFS) - With Prescription Drug Coverage - click here

This letter will provide your physicians with important information about your Advantra Freedom (PFFS) health plan and guide them in administering the plan benefits with ease and assurance.

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

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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.

This statement or form should be completed by supplying the requested information and should be sent to Advantra Freedom (PFFS) at:

Advantra Freedom (PFFS)
Coventry Health Care, Inc.
2222 Ewing Road
Moon Township, PA 15108

Authorization Agreement for ACH Debit Form

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Complete this form to have your Advantra Freedom (PFFS) premium deducted from your bank account each month.

 

For questions about any of these forms call Advantra Freedom (PFFS) Customer Service at 1-866-714-9291; TTY/TDD users should call 1-866-386-2335, Monday through Friday, 8:00 a.m. - 10:00 p.m., ET. From November 15th through March 1st additional Saturday hours, 8:00 a.m. - 4:00 p.m. ET.