Forms
Below is a list of forms and a brief description of its use. .
| form name | use |
|---|---|
 Coverage Determination Request Form |
Submitted to request that we cover a prescription not currently included in the plan in which a member is enrolled. A doctor typically fills this out for the member. |
| Appointment of Representative |
Used to appoint any individual, including an attorney, to represent a member during the processing of a claim or claims, and/or any subsequent appeal or in in connection with any aspect of dealing with an insurance provider. |
| Member Appeals Form |
Filed when you do not agree with a decision made by us regarding a request for coverage or payment of service you requested. |
| Grievance Form Letter |
Filed when you have a complaint about service received from one of our network providers, e.g., a pharmacy or doctor. |
| CMS Standard Coverage Determination Request Form |
|
| Model CoverageDetermination Request Form |
|
| Drug Evaluation Review Coverage Determination |
**NOTE All forms require Adobe Acrobat Reader to view.
Questions or Concerns?
Our team of friendly bi-lingual representatives are available to answer your questions Monday - Friday from 8am to 8pm.
 |
(866)231-7201 - TOLL FREE |
 |
(888)659-0618 - TOLL FREE |
 |
MemberServices@MyPreferredCare.com |
