Medicare Forms
Phelps Health Medicare Advantage
As a Phelps Health Medicare Advantage member you have easy access to documents and forms.
Enrollment
Enrollment Form
We make enrolling in the Phelps Health Medicare Advantage plan easy. You can apply online or print the form and mail the completed form to our office. Remember, if you want to enroll in a Medicare Advantage plan, you must first be enrolled in Medicare Part A and Part B (Original Medicare). If you have questions call our team of experts at 1-855-752-3795 (TTY: 711).
Authorization for the Use or Disclosure of Protected Health Information
As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Phelps Health Medicare Advantage may not use or disclose your health information except as provided in our Notice of Privacy Practices without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information (PHI) described herein.
Scope of Appointment
The Centers for Medicare & Medicaid Services (CMS) requires sales agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.
Appointment of Representative
You can appoint a relative, friend, advocate, caregiver, or anyone else to act on your behalf for healthcare-related affairs. If you choose to have someone act for you, then you and that person must sign and submit an Appointment of Representative Form.
Care Coordination Form
Benefits
Evidence of Coverage
Evidence of Coverage (EOC) gives you details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2026. It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place.
Summary of Benefits
The Summary of Benefits provides an overview of what we cover and what you pay. It does not list every service we cover or list every limitation or exclusion. For a complete list of services we cover refer to the Evidence of Coverage.
Annual Notice of Change
The Annual Notice of Change is a yearly update providing changes to current plan. The plan is new for 2026; this will be updated in 2026.
Over-the-Counter
Your plan coverage includes Over-the-Counter benefits that help purchase approved medical items by phone, mail, internet, and at select retail locations.
SilverSneakers®
SilverSneakers® is more than a fitness program! Keep moving for a healthier lifestyle at local fitness centers, live on the web, on-demand videos, and with the SilverSneakers GO mobile app.
Diabetic Drug Resource
Review information for Tier 6 $0 copay insulin, preferred Glucose test strips, and preferred Continuous Glucose Monitoring products.
Claim Forms
Medical Expense Reimbursement Claim Form
Use this form to request reimbursement for out-of-pocket medical expenses for the treatment of a covered condition.
Flu Vaccine Reward Form
Complete and return this form if your flu shot was received at a location other than your primary care physician’s office. This includes a pharmacy, walk-in clinic, and health department. You are eligible to receive one $10 reward annually during the coverage year. Rewards will be loaded on your Flex Card after verification of eligibility.
Pharmacy
Prescription Drug Claim Form
You may need to ask us for reimbursement and can use this form if you have received a bill or paid for a prescription that you think we should pay for. See also Chapter 7 of the Evidence of Coverage (Asking us to pay our share of a bill you have received for covered medical services or drugs) for more information and examples for when reimbursement may be appropriate.
Medicare Prescription Drug Coverage Determination Form
A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your Part D prescription drugs. You, your appointed representative, or your prescriber have the right to request a coverage determination.
Redetermination Request of Medicare Prescription Drug Denial Form
If your coverage determination for a prescription drug was denied, you have the right to ask us for a redetermination (appeal) of our decision. You have 65 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
Medicare Prescription Payment Plan Enrollment Form
The Medicare Prescription Payment Plan is a new option that works with your current drug coverage to help manage out-of-pocket costs by spreading them across the calendar year. To enroll in the Medicare Prescription Payment Plan complete and submit the enrollment form.
Personal Medication List
Use the Personal Medication List to help you and your health care providers keep track of the medications you are taking.
Prescription Mail Order Form
If you rely on regular or long-term medications, there may be a better way to get your prescriptions filled. Home delivery is a smart, simple way for you to get prescriptions delivered to your door. Mail order can save you money on your prescription co-pays with a 3 months supply.
Coverage Forms
Optional Self-Referral for Case Management
If you would like a member of our Case Management team to contact you, please complete the information below. Our Case Management nurses can assist you in obtaining optimal medical and pharmacological services for complex medical conditions (such as diabetes, asthma, heart disease). Case Management services are provided at no cost!
Medicare Appeals Form (Optional)
Medical Care Coverage Decisions
Phelps Health Medicare Advantage requires you or your physician to get prior authorization for certain services and drugs. This means you will need to get approval from Phelps Health Medicare Advantage in some cases before you received care or fill prescriptions. If you do not get approval, Phelps Health Medicare Advantage may not provide coverage. If prior authorization is required, your physician must complete the Medicare Coverage Decision form
Other
Multi Language Services
We have free interpreter services to answer any questions you may have about the Phelps Health Medicare Advantage plan. To speak with an interpreter, call 1-855-752-3795 (TTY: 711). There is no cost for this service.