Forms and Documents

Find Medicare Advantage, prescription drug, Medicare Supplement and other forms you need to help you manage your Medicare plan.

Medicare Advantage Plan Documents

Prescription Drug Plan Documents

Medicare Supplement Insurance Plan Documents

View these forms and documents in Spanish. If you have questions, please Contact Us.

General Plan Information

• Automated Premium Payment (ACH) Form (MAPD)
• Automated Premium Payment (ACH) Form (PDP)
• CMS Appointment of Representative Form (MAPD)
• CMS Appointment of Representative Form (PDP)

Prescription Drug Information

• Mail-Order Physician New Prescription Fax Form
  
• Medicare Part B vs. Part D Form
• Online Coverage Determination Request Form
• Online Coverage Redetermination Request Form
• Personal Medication List (MAPD and PDP)
• Pharmacy Mail-Order Form
• Prescription Drug Claim Form
• Prescription Drug Coverage Determination Request Form (MAPD)
• Prescription Drug Coverage Determination Request Form (PDP)
• Prescription Drug Coverage Redetermination Request Form (MAPD)
• Prescription Drug Coverage Redetermination Request Form (PDP)
• Prescription Drug Formulary Exception Physician Form
• Prescription Drug Tier Exception Physician Form

Other

• Access Additional Privacy Forms
• Authorization to Disclose Protected Health Information (PHI) Form
• Late Enrollment Penalty (LEP) Appeals
• Notice of Privacy Practices

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.