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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/Appeal Request Click Here  
Part D Coverage Redetermination Click Here  
Part D Direct Member Reimbursement Form
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   
CVS Caremark Mail Service Order Form  

Always at Your Service

Call Member Services at 713-442-CARE (2273)
or toll-free at 1-866-535-8343 (TTY: 711)

8 a.m.– 8 p.m. | 7 days a week | From October 1 to March 31

8 a.m.– 8 p.m. | Monday – Friday | From April 1 to September 30

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