Additional Forms and Documents

Appointment of Representative Form

Our members can appoint a caregiver to act on their behalf. To do so, we must have written authorization signed by both the caregiver and the member.

A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Download an Appointment of Representative form. Once the form is filled out in its entirety fax it to the Customer Service at 1-866-245-4120.

Redetermination Request Form

If you don't agree with the initial claim decision by Medicare, you should use this Redetermination Form to appeal your claim. This is called a redetermination and is the first level of the appeals process. This is done by the Medicare Contractor who processed your claim. Any dollar amount can be appealed at this level, but it needs to be submitted within 120 days from the date you received the initial claim decision. This is normally the date shown on your Medicare Summary Notice (MSN). To file an appeal, you can also follow the instructions on your MSN by signing and returning the notice to the Medicare Contractor who processed your claim.

To file a Redetermination Form, you can send or fax the form to us in writing at:

• MAXIMUS
  1040 First Avenue, Suite 200
  King of Prussia, PA 19406
• Fax: 1-484-688-5601

You may also file a Redetermination Form by phone or fax. To file an appeal, or if you have any general questions about the Redetermination Form, call us at 1-866-568-8921 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) every day

Exception and Prior Authorization Forms

Print Exception and Prior Authorization forms, or use our easy Drug Search tool to find the forms you need.

Learn more about Exceptions and Prior Authorizations.

Request for a Medicare Prescription Drug Coverage Determination Form

You, an appointed representative, or your prescribing physician may use this form to request a coverage determination from the plan.

Learn more about Exceptions and Prior Authorizations.

2010 Change Notice Form

Current Today’s Options PFFS members can use this change form to change their enrollment election to a different Today’s Options PFFS plan, change their premium payment option or to update contact information.

Direct Claims Form (PDF)