Forms
Documents on this page are available in Portable Document Format (PDF). Adobe Reader (free) may be used to open these files.
- Advance Directives - Information on Advance Directives including the Living Will and Health Care Surrogate
- Appointment of Representative Form (pdf 65.81 kB) - Assign someone to represent you in accordance with HIPAA regulations using an Appointment of Representative form.
- Appointment of Representative Form Instructions.
- Authorization to Disclose Protected Health Information (pdf 29.35 kB) .
- Communication Directive (pdf 30.16 kB) - Specify who can communicate with your health care team using the Communication Directive Form.
- These forms can be used to request an exception to your drug coverage:
- Request for Medicare Prescription Drug Coverage Determination Form (pdf 37.84 kB) is for member and healthcare provider use.
- Request for Redetermination of Medicare Prescription Drug Denial Form (20 45.52 kB)
- Enrollment Application (pdf 104.50 kB) - 2012 Capital Health Plan Advantage Plus (HMO) amd Capital Health Plan Preferred Advantage.
- Enrollment Application (pdf 81.18 kB) - 2012 Capital Health Plan Retiree Advantage (HMO).
- Medicare Complaint Form You are now able to submit feedback about your Medicare health plan or other non-urgent issues directly to Medicare using the Medicare Complaint Form.
- The Office of the Medicare Ombudsman - The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.
H5938_WEB 008 CMS Approved 01042012
Last Updated 12/21/11
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