Member Forms

For assistance with any of these forms, please contact customer service.


Prescriptions/pharmacy/authorizations

Mail order form — for filling new prescriptions from Health First Family Pharmacy (for more information, visit Health First Family Pharmacy).

Mail order form for filling prescriptions from MedVantx — you must use MedVantx if you need your drugs shipped outside of Florida. For more information visit MedVantx.

 Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it

 Pharmacy authorization/exception request form — if a drug requires prior authorization or an exception, your doctor should submit this form with applicable medical information to our Pharmacy Team for consideration.

 Medicare prescription drug exception & appeal form — to request an authorization, formulary exception (for a drug that is not on our formulary), or a tiering exception (to pay less for a covered drug because you can’t take a lower-cost drug), or an appeal if we deny coverage for your drug or deny your exception request. For exception requests, your doctor must call or write us to explain why it is medically necessary.

 Authorization request (medical) — for your physician to request authorization for a medical service 

Claims

 Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it

 Medical reimbursement form — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services

Premiums

 Automatic payment form — if you would like to have your premium automatically charged to your credit card or withdrawn from your bank account each month

Other

 Enrollment Request Form (2014) (Español)

 Disenrollment Form (2014)

 Appointment of representation form —  if you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle appeals and grievances with us on your behalf

Authorization to disclose your Protected Health Information (PHI) form — if you want to give someone permission to access your personal health information (for example claims, medical, or financial information)


 

Y0089_MP3536FH Approved 11/06/2013
Last updated: 01/17/2014