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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 713-321-2262. 

 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)

 

Download - Spanish

HIPAA Release of Information  

 

Download -Spanish

Email Opt-In Form Click Here 
Vision Reimbursement  
Update Your Address Click Here   

Always at Your Service

Whether you're choosing a Medicare plan for the first time, looking to make a change, or helping someone else evaluate their Medicare options, we're here to help! Call to Speak with an Enrollment Specialist at 713-442-5646 or

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