Advantra Freedom (PFFS) 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.

Member Letter to Provider

Advantra Freedom (PFFS) 4, 5, and 7 - Click here to download PDF

Advantra Freedom (PFFS) 1, 2, 3, and 6 - Click here to download PDF

This letter will provide your physician with important information about your Advantra Freedom (PFFS) health plan and guide her or him 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.

Medicare Prescription Drug Forms

Part D Forms are posted on the Formulary page.

Click here to access these forms.

 

Understand whether or not services you are about to receive are covered benefits.  If you are at all unsure or have questions, you should contact Advantra Freedom (PFFS) Customer Service at 1-866-386-2330; TTY/TDD at 1-866-386-2335 for the hearing impaired, Monday through Friday, 8:00 a.m. - 10:00 p.m., ET, November 15 through March 1, additional Saturday hours, 8:00 a.m. - 4:00 p.m. ET.  Part D Customer Service is available 24 hours a day, 7 days a week.