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Medicare Forms

Below are the forms most commonly needed by Medicare plan members. The forms on this page are for our Medicare Advantage plans. Please click here for forms for our Medigap plans.

If you do not find the Medicare form you are looking for in this section, please contact our office at 1-800-541-8981. TTY users should call 711. From November 15 through March 1 our telephone hours are 8 a.m. to 8 p.m. seven days a week. After March 1 our telephone hours are 8 a.m. to 8 p.m., Monday through Friday, and you may leave a message on Saturdays, Sundays and holidays. We will return your call on the next business day.

Medicare Advantage and Part D Forms

Form

Description
GENERAL FORMS

Surepay Information and Authorization Form
• 2012 (PDF)

Use this form to set up automatic payment of premium from your personal bank account for Asuris TruAdvantage plans.

Authorization for Use and Disclosure of Protected Health Information

Authorization for Asuris Northwest Health to disclose health information to a designated party for a specific purpose.

Application Form for Asuris TruAdvantage plans
• 2012

Use this form to apply for Asuris TruAdvantage coverage. Enrollment is subject to eligibility and enrollment or election periods.

Medicare beneficiaries may enroll in Asuris TruAdvantage through the CMS Medicare Online Enrollment Center located at www.medicare.gov.

Coverage Determination Form (Members)

Members: Use this form for requesting coverage decisions.
Coverage Determination Form (Providers) Providers: Use this form for requesting coverage decisions.
PRESCRIPTION FORMS
Prescription Claim Form Use this form to submit for reimbursement of covered medications you may have purchased without using your member card.

Postal Prescription Services (PDF)

Use this form for mail order prescriptions from Postal Prescription Services.
GRIEVANCE AND APPEALS FORMS

Appeal Form for Medical

Use this form to request an appeal to a medical coverage decision.

Appeal Form for Prescription
• Asuris TruAdvantage + Rx Classic
• Asuris TruAdvantage + Rx Enhanced

 Use this form to request an appeal to a prescription medication coverage decision.

Complaint Form

Use this form to file a complaint/grievance with us.

Appointment of Representative

Use this form to appoint another individual to act on your behalf.

Last Updated 01/27/2012
Pending CMS Approval
Y0062_2012_MEDICARE_ADVANTAGE_AND_SCRIPT CMS APPROVED MMDDYYYY

 

Below are forms for Asuris Pledge Medigap plans. If you do not find the forms you are looking for, please call us at 1-866-704-2708 from 8 a.m. to 5 p.m., Monday through Friday, Pacific time.

Medigap (Medicare Supplement) Forms

Form

Description

Application Form for Asuris Pledge Medigap plans
• 2010 (PDF)

Use this form to apply for Asuris Pledge Medigap coverage. (Optional) Fill out the Surepay section of this form to set up automatic payment of premium from your personal bank account.

 

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