Forms & Information You Might Find Useful

Electronic Funds Transfer (EFT) or ACH Authorization Form

My Plan and Coverage Information page top | go back

Requesting a Person to Represent Me or Have Access to My Confidential Information page top | go back

  • Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.

Use the Plan's Coverage for your Medical Servicespage top | go back

Formularios Disponibles en Espanol page top | go back

H0302_1301_2018 CMS Approved 10/13/2017