Member Forms
Legal
- Advanced Directive. Use this form to gives instructions for your health care in the event that you are no longer able to make or communicate those decisions yourself.
- CMS Appointment of Representative Form. Use this form to appoint someone to represent you on formal matters, such as appeals or grievances.
- Release of Information Form. Use this form to allow loved ones to access your protected health information.
- VA Release of Information Form. Use this form to authorize the Department of Veterans Affairs to release health-related information to those you designate.
Prescription Drugs
- CVS Caremark Prescription Mail Order Form. Use this form to start mail-order pharmacy services.
- Request for Medicare Prescription Drug Coverage Determination. Use this form to request a coverage determination or exception to MercyOne Health Plan’s drug formulary.
- Request for Redetermination of Medicare Prescription Drug Denial. Use this form to file an appeal related to your Part D prescription drug benefits.
Prior Authorization
- Prior Authorization Form. You or your provider can use this form to request prior authorization for services that require it.
Reimbursement
- CVS Caremark Drug Claim Form. Use this form to be reimbursed for out-of-pocket covered prescription medication.
- Direct Member Reimbursement Request Form. Use this form to request reimbursement for glasses after cataract surgery or other allowable medical expenses.