For assistance with any of these forms, please contact customer service.
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 (by clicking this link you will be leaving Health First Health Plans' web site).
Prescription drug reimbursement form — to request reimbursement for a covered prescription 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
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
Automatic payment form — if you would like to have your premium ally withdrawn from your monthly Social Security payment, withdrawn from your bank account each month or charged to your credit card
Disenrollment form — for current members to change from one of our plan options to another.
Medical Prior Authorization List — for prescription drugs requirements, see plan formularies.
Pharmacy Authorization Request Form — for prescription drugs requirements, see plan formularies.
Plan selection form (2015) — for current members to change from one of our plan options to another (for example, change from Value to Classic)
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)
Pro-Health hold form — If you’re already a member of Pro-Health and then join Health First Health Plans, it’s your responsibility to contact Pro-Health's billing office to fill out a "hold form" to cancel your membership payments.
Y0089_MP4369 CMS Approved 11052014
Last updated: 10/01/2014