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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-CARE (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  

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