Member Forms
For assistance with any of these forms, please contact our Care Team.
Prescriptions/pharmacy/authorizations
- 2022 Request for Redetermination of Medicare Prescription Drug Denial (updated 10/17/2022) — Use this form to request an appeal (redetermination) if we have denied your request for coverage of (or payment for) a prescription drug.
- 2022 Medical Authorization Request Form (updated 08/01/2022) — for your physician to request authorization for a medical service.
Claims
- Prescription Drug Reimbursement Form (updated 08/01/2022) — to request reimbursement for a covered prescription if you paid out-of-pocket for it.
- 2021 Medical Reimbursement Form (updated 08/01/2022) — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services.
- 2022 Medical Reimbursement Form (updated 08/01/2022) — If you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services.
Other
Please send completed form(s) to the address found on each form:
- Enrollment Request Form 2022 — Use this form if you will be joining our Medicare Advantage plan.
- Disenrollment Form — For current members to disenroll and change to an outside or non-Health First Health Plan.
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Appointment of Representation Form (updated 08/03/2022) — if you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle appeals and grievances with us on your behalf.Once complete, please return this form to:
AdventHealth Advantage Plans
MA Grievance and Appeal Communications
PO Box 62378
Phoenix, AZ 85082 - Authorization to Disclose Your Protected Health Information (PHI) Form — if you want to give someone permission to access your personal health information (for example claims, medical, or financial information).
- For 2022: OTC Network — If you want to learn more about or to use your over-the-counter (OTC) network. This includes over-the-counter drugs and supplies.
AdventHealth Advantage Plans is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.
Y0089_EL9652AH_M | Accepted date: 10/01/2021
Last updated: 08/18/2022