Documents & Forms Center

Providers

Instructions for completing Prior Authorization Form

Instructions for completing Prior Authorization Form.pdf

Medicare, Members

Medicare Prescription Drug Reimbursement Request

MCR Prescription Drug Request for Reimbursement.pdf

Medication Prior Authorization Request

Universal Prior Authorization Form.pdf

Agents, Employers, Members

Member Status Change Form

Member Status Change Form 2020.pdf

Medicare

MTMP Personal Medication List

MTMP Personal Medication List.pdf

Members

Non-Medicare Appointment of Representation Form

COM AOR form_3.11.15.pdf

Agents, Employers, Members

Non-Medicare Prescription Drug Reimbursement Request

Non-Medicare Prescription Drug Reimbursement Request _ 2022 Updated.pdf

Members

Parental Consent for Care of Minor Children

Parental-Consent-for-Minor-Children_CHP-41.pdf

Agents, Employers

Premium Billing Reconciliation

ReconciliationExample.xlsx

Medicare

Request for Medicare Prescription Drug Coverage Determination Form

2021 Request for Prescription Drug Coverage Determination.pdf

Agents, Employers, Members

Universal Prior Authorization Form

Universal Prior Authorization Form FILLABLE.pdf

Providers

Universal Prior Authorization Form

Universal Prior Authorization Form FILLABLE.pdf

Agents, Employers, Members

Vision Reimbursement Request

Vision-Reimbursement-Request_0-1.pdf

Waiver of Liability Statement for Providers

Waiver of Liability Statement for Providers.pdf

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