Forms and Documents
Find Medicare Advantage, prescription drug, Medicare Supplement and other forms you need to help you manage your Medicare plan.
Medicare Advantage Plan Documents
2019 Online Coverage Determination Request Form
2019 Online Coverage Redetermination Request Form
2019 Mail-Order Physician New Prescription Fax Form
2019 Prescription Drug Claim Form
2019 Medicare Part B vs. Part D Form
2019 Authorization to Disclose Protected Health Information (PHI) Form
2019 CMS Appointment of Representative Form
2019 Notice of Privacy Practices
2019 Access Additional Privacy Forms
2019 Automated Premium Payment (ACH) Form (PDP)
2019 Automated Premium Payment (ACH) Form (MAPD)
2019 Prescription Drug Coverage Determination Request Form (PDP)
2019 Prescription Drug Coverage Redetermination Request Form (PDP)
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Prescription Drug Formulary Exception Physician Form
2019 Prescription Drug Tier Exception Physician Form
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.
2020 Online Coverage Determination Request Form
2020 Online Coverage Redetermination Request Form
2020 Mail-Order Physician New Prescription Fax Form
2020 Prescription Drug Claim Form
2020 Medicare Part B vs. Part D Form
2020 Authorization to Disclose Protected Health Information (PHI) Form
2020 CMS Appointment of Representative Form
2020 Notice of Privacy Practices
2020 Access Additional Privacy Forms
2020 Automated Premium Payment (ACH) Form (PDP)
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 Prescription Drug Coverage Determination Request Form (PDP)
2020 Prescription Drug Coverage Redetermination Request Form (PDP)
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Prescription Drug Formulary Exception Physician Form
2020 Prescription Drug Tier Exception Physician Form
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.
Last Updated: 09302019
Y0096_WEB_IL_MM20
Last Updated: 09302019
Y0096_WEB_IL_MM20