Forms

Pharmacy forms

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

Medical forms

• Medicare beneficiary request for payment (PDF)

Other forms

• Appointment of Representative (AOR) Form (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)
  The form gives us permission to discuss or disclose your protected health information (PHI) to the individual that you have named on the HIPAA form. It must be signed by you or your personal representative.
• Attestation of Disenrollment Form (PDF)
• Disenrollment Form (PDF)
• Health Care Privacy Complaint Form (PDF)
  Use this form to file a complaint regarding the Keystone First VIP Choice (HMO-SNP) privacy policies, procedures, and practices or compliance with our Notice of Privacy Practices or state and federal privacy rules and laws.
• Personal Representative Request Form (PDF)
  This form will be used to confirm a member's permission that Keystone First VIP Choice may discuss or disclose PHI to a particular person who acts as the member's personal representative.
• Request to Amend Protected Health Information (PDF)
  Use this form to request an amendment of your protected health information (PHI).
• Request for Alternate Means of Confidential Communications (PDF)
  Use this form so that communications of your protected health information (PHI) are carried out by alternative means or at an alternate location.
• Revocation of Alternate Means of Confidential Communications (PDF)
  Use this form to revoke a confidential communications request previously given.
• Request for List of Disclosures of Protected Health Information (PDF)
  Use this form to request an Accounting of Disclosures of your protected health information (PHI).
• Request to Restrict the Use and/or Disclosure of Protected Health Information (PDF)
  Use this form to ask us to restrict the use and/or disclosure of your protected health information (PHI).