to main content

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  
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.