Forms
Prescription drug lists can now be found on our Prescription Drugs and Formularies page.
Advance Directives
My Advance Care Plan (Form)
PDF, 367 KB
PDF, 367 KB
My Advance Care Planning Guide
PDF, 2 MB
PDF, 2 MB
Alternate Addresses
Alternate Address Form
PDF, 21 KB
PDF, 21 KB
Authorizations for Release of Medical Information
Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY
PDF, 285 KB
PDF, 285 KB
Authorization for Use or Disclosure of Medical Information (Designated Representative)
PDF, 165 KB
PDF, 165 KB
Authorization to Release/Obtain PHI
PDF, 101 KB
PDF, 101 KB
Autorización Para Rizacion Para Divulgar y Obtener Información Médica Protegida (PHI)
PDF, 179 KB
PDF, 179 KB
Disabled Dependent Certification Form
PDF, 125 KB
PDF, 125 KB
Formulario para la autorización de un representante designado
PDF, 237 KB
PDF, 237 KB
Personal Health Information (PHI) Restriction Form
PDF, 79 KB
PDF, 79 KB
Revocation of Authorization Form
PDF, 137 KB
PDF, 137 KB
Auto Debit
Claims
Coordination of Benefits
Complaints and Member Appeals
File an appeal about a coverage decision for Part C medical services or items
PDF, 655 KB
PDF, 655 KB
File a complaint with Optima Medicare
PDF, 649 KB
PDF, 649 KB
Members Appeals Packet
PDF, 943 KB
PDF, 943 KB
Members Complaints Packet (Family Care)
PDF, 100 KB
PDF, 100 KB
Members Complaints Packet (Family Care)
PDF, 100 KB
PDF, 100 KB
File an appeal for medical items or services for Optima Community Complete (HMO D-SNP)
PDF, 1010 KB
PDF, 1010 KB
File a complaint with Optima Community Complete (HMO D-SNP)
PDF, 1001 KB
PDF, 1001 KB
Optima Community Complete Appeals
PDF, 109 KB
PDF, 109 KB
Optima Community Complete Request for Drug Coverage Determination
PDF, 155 KB
PDF, 155 KB
Request a Redetermination (appeal) for a Optima Community Complete (HMO D-SNP) Prescription Drug
PDF, 127 KB
PDF, 127 KB
Optima Medicare Rx (PDP) Coverage Determination Request
PDF, 155 KB
PDF, 155 KB
Optima Medicare Rx (PDP) Coverage Redetermination Request
PDF, 127 KB
PDF, 127 KB
Request a standard decision for Medicare Part D (prescription drugs)
PDF, 155 KB
PDF, 155 KB
Request for Medicare Prescription Drug Coverage Redetermination
PDF, 127 KB
PDF, 127 KB
Pharmacy Mail Order
2023 Medicare Home Delivery Prescription Drug Form
PDF, 735 KB
PDF, 735 KB
Mail Order Frequently Asked Questions
PDF, 445 KB
PDF, 445 KB
Mail Order Pharmacy Privacy Notice
PDF, 71 KB
PDF, 71 KB
Mirena Eligibility Form
PDF, 71 KB
PDF, 71 KB
Mirena Order Form
PDF, 42 KB
PDF, 42 KB
Proprium Pharmacy Frequently Asked Questions
PDF, 116 KB
PDF, 116 KB
Sentara Home Infusion Pharmacy Request Form for Injectables
PDF, 153 KB
PDF, 153 KB
Specialty Pharmacy FAQs (Proprium Pharmacy)
PDF, 168 KB
PDF, 168 KB
Pharmacy Reimbursement
2022 English & Spanish Medicare Member Reimbursement Form
PDF, 218 KB
PDF, 218 KB
2023 Commercial and Medicaid Member Reimbursement Form
PDF, 114 KB
PDF, 114 KB
2023 Medicare Member Reimbursement Form
PDF, 1 MB
PDF, 1 MB
2023 Medicaid Member Reimbursement Form
PDF, 103 KB
PDF, 103 KB
2023 Medicare Member Reimbursement Form (Spanish)
PDF, 1 MB
PDF, 1 MB
Instructions for Pharmacy Reimbursement
PDF, 141 KB
PDF, 141 KB