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Medicare
Centers for Medicare & Medicaid Services (CMS) Forms
Prior Authorization Form -
Physicians should use this form when requesting prior authorizations and providing a supporting statement for an exception request.
Prescription Drug Claim Form -
You must complete this form if you need to be considered for prescription reimbursement. Consideration for reimbursement is necessary if you go to an out-of-network pharmacy, or if you go to your network pharmacy without your ID card.
Formulario de reclamación de medicamento recetado -
Usted debe llenar este formulario si desea que se le considere para reembolsarle el gasto de un medicamento. La consideración para reembolso es necesaria si usted va a una farmacia fuera de la red, o si va a una farmacia de la red sin su tarjeta de identificación.
Appointment of Representative Form -
Complete this form if you wish to appoint a representative to ask for a coverage determination (decision on a requested service) on your behalf. You can name a relative, friend, advocate, doctor, or anyone else you want to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at Affinity Health Plan, Attn: Customer Service, 2500 Halsey Street, Bronx, NY 10461. You can call Customer Service to learn how to name your appointed representative at 1-877-234-4499 (TTY/TDD: 1-800-662-1220).
You also have the right to have an attorney (lawyer) ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.
Medicare Part D Coverage Determination Request Form -
You may use this form to request a coverage determination. When Affinity Health
Plan makes a coverage determination, we are making a decision about whether or
not to provide or pay for a Part D drug. Coverage determinations include
exception requests and can be done by phone, fax or mail. Members or their
authorized representative can call 1-800-417-3367 (TTY/TDD: 1-800-899-2114).
Physicians should contact 1-800-417-8164 24 hours a day, 7 days a week or fax
documentation to 1-877-837-5922. Any form can be used, but we have provided this
form for your convenience.
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