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Uniform Glossary
of Terms (PDF)

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Medicare Forms
Medicare Advantage plans
Asuris TruAdvantage (PPO) Enrollment form
• 2014 (PDF)

Apply for an Asuris TruAdvantage (PPO) plan.

*Enrollment is subject to eligibility and enrollment or election periods.

Automatic Bank Deduction Authorization form (PDF)

Set up automatic payment of your Medicare Advantage premium.

Authorization for Use and Disclosure of Protected Health Information (PDF) Complete this form to authorize us to disclose your information to a person (or entity) for a specific purpose.
Short Enrollment form
• 2014 (PDF)		 Change between Asuris TruAdvantage (PPO) Basic, Asuris TruAdvantage (PPO) + Rx Classic or Asuris TruAdvantage (PPO) + Rx Enhanced plans.
Prescription
Catamaran Rx Home Delivery form (PDF) Order prescriptions to be delivered to your home from Catamaran Rx.
Postal Prescription Services form (PDF)
Use mail-order prescriptions from Postal Prescription Services.
Walgreens Mail Service brochure (PDF) Get information about Walgreen’s prescription mail-order service.
Walgreens Mail Service Prescriber fax form (PDF) Submit mail-order prescriptions to Walgreens via fax. Valid only if sent from the prescriber's office.
Walgreens Member Registration and Mail-Service Order form (PDF) Use this form to register and submit your first prescription order to Walgreens Mail Service.
Prescription Claim form (PDF) Request reimbursement for covered medications you paid for directly.
Request for Medicare Prescription Drug Coverage Determination (PDF) Members and providers: Request a formulary or tiering (copay level) exception, prior authorization or reimbursement of a prescription drug.
Grievance & appeals
Appointment of Representative (PDF) Appoint someone to act on your behalf.
Complaint form (PDF) File a complaint or grievance with us.
Medical Appeal form (PDF) Request an appeal to a medical coverage decision that you disagree with.
Prescription appeals form (PDF)
 Request an appeal to a prescription coverage decision that you disagree with.

Note: To print a PDF document, you need Adobe® Acrobat® Reader. Adobe.com

Last Updated 07/14/2014
Y0062_2014_V6_MEDICARE Approved

 

 
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