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Medical Reimbursement Form

Medical Reimbursement Form (Spanish)

How to enroll in ${anCompany} Medicare plan

Let someone else talk to us about your health or coverage

• One-time only: You can give us your permission by phone. We can speak with that person during that call.
• On an ongoing basis: You may want someone to speak with us more often. If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. It lets this person access your personal health information. They can also speak with us on your behalf.

Open and print the PHI form

Open and print the PHI form (Spanish)

Let someone file a grievance (complaint), ask for coverage or make an appeal for you

• You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form.
• Fill out this form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave ${company} Medicare and go to the CMS website if you link to the form.

Appointment of Representative CMS Form

Appointment of Representative CMS Form (Spanish)

Learn more about requesting an exception or filing a grievance or appeal:
Access forms and learn what steps to take