Forms

Pharmacy forms

• Coverage Determination (exception) Request Form (PDF) PDF
• Over-the-counter (OTC) catalog and order form (PDF) PDF
• Personal Medication List (PDF) PDF
• Prescription Claim Form (PDF) PDF
• Recommended To-Do List (PDF) PDF
• Request for Redetermination of Medicare Prescription Drug Denial (Online)
• Request for Redetermination of Medicare Prescription Drug Denial (PDF) PDF

Other forms

• Appointment of Representative (AOR) (PDF) PDF
  Use this form to appoint a representative to act on your behalf regarding your appeal request.
  Appointment of Representative Form instructions
• Authorization for Disclosure of Health Information (PDF) PDF
  The form gives us permission to discuss or disclose your protected health information (PHI) to the individual that you have named on the form. It must be signed by you or your personal representative.
• Disenrollment Form (PDF) PDF
• Attestation of Disenrollment Form (PDF) PDF
• Personal Representative Request Form (PDF) PDF
  This form will be used to confirm a member's permission that First Choice VIP Care may discuss or PHI to a particular person who acts as the member's personal representative.