Medicare Forms and Information


Authorization to Disclose Protected Health Information (PHI) Form

Automated Premium Payment (ACH) Form

CMS Appointment of Representative

Mail-Order Physician New Prescription Fax Form

Notice of Privacy Practices

Pharmacy Mail-Order Form

Prescription Drug Claim Form - HMO

Prescription Drug Claim Form - HMO-POS

Prescription Drug Claim Form – PPO

This information is available for free in other languages. Please call our Customer Service number at 1-877-774-8592. (TTY/TDD users should call 711). We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al Cliente llamando al 1-877-774-8592. (Los usuarios de TTY/TDD deberán llamar al 711). Nuestro horario es de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

Contact Medicare for more information about Medicare benefits and services, including general information about Medicare Advantage Prescription Drug coverage.


1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.

If you are hearing or speech impaired, please call 1-877-486-2048.


If you would like to submit feedback directly to Medicare, please use the Medicare Compliant Form or contact the Office of the Medicare Ombudsman .