Call Member Services at 713-442-CARE (2273)
or toll-free at 1-866-535-8343 (TTY: 711)
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 |
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Appointment of Representative (AOR) | ||
HIPAA Release of Information | ||
Email Opt-In Form | Click Here |
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Vision Reimbursement |
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Update Your Address | Click Here | |
CVS Caremark Mail Service Order Form |