Forms
Below are a list of important member forms:
2026 Enrollment Form (English | Spanish) or 2027 Enrollment Form (English | Spanish): fill out to enroll in our plans
Hospice form: information to override an Hospice A3 reject or to update hospice status
Prior Authorization: please fill out the form to get authorization for services
Aetna Medicare FIDE (HMO D-SNP) Coverage Redetermination Form - English | Spanish | Vietnamese | Arabic you have 65 days from the date of our Notice of Denial
Coverage Determination form - Spanish
Coverage Determination form - Vietnamese
Coverage Determination form - Arabic
AOR Form: Please fill out If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.”
Additional forms: Additional Forms: Authorization to Release Protected Health Information (PHI); Authorization to Release Psychotherapy Notes
Medicare Prescription Payment Plan Participation request form - English | Spanish | Arabic | Vietnamese
Wig reimbursement form - English | Spanish
Provider attestation of Patient Characteristics for SSBCI Eligibility - English | Spanish | Vietnamese