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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
2024 Vision Reimbursement   Download - English
Download - Spanish
Update Your Address Click Here  
CVS Caremark Mail Service Order Form  
Automated Monthly Premium EFT Authorization Form   Download
Premium Withhold Option Form   Download
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Need Answers?

Call our Concierge team at 713-442-CARE (2273) or toll-free at 1-866-535-8343 (TTY: 711)

From October 1 to March 31

8 a.m. - 8 p.m.

7 days a week

From April 1 to September 30

8 a.m. - 8 p.m.

Monday - Friday

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