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Member Forms

If you need assistance completing a form or have questions about which form to complete, please call member services at 713-442-2273. 

 Form Name Online Form PDF Download
Part D Coverage Determination/Exception Request Click Here  
Part D Coverage Redetermination Click Here 
Part D Reimbursement
Other Coverage Questionnaire Click Here 
Appointment of Representative (AOR)        
HIPAA Release of Information    
Email Opt-In Form Click Here 
Vision Reimbursement  
Update Your Address Click Here   

Always at Your Service

Call Member Services at 713-442-CARE (2273) or toll-free at 1-866-535-8343 (TTY: 711) from 8 a.m. to 8 p.m., seven days a week, from October 1 to March 31 and 8 a.m. to 8 p.m., Monday through Friday, from April 1 to September 30.

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