Forms

My Advance Care Plan (Form)

My Advance Care Planning Guide

Alternate Address Form

Authorization for Use or Disclosure of Medical Information - THIS FORM MUST BE USED BY HEALTH EQUITY MEMBERS ONLY

Authorization for Use or Disclosure of Medical Information (Designated Representative)

Authorization to Release/Obtain PHI

Autorización Para Rizacion Para Divulgar y Obtener Información Médica Protegida (PHI)

Disabled Dependent Certification Form

Formulario para la autorización de un representante designado

Personal Health Information (PHI) Restriction Form

Revocation of Authorization Form

Auto Debit Form for Individual & Family Plan Members

Behavioral Health Claim Instructions

Instructions on How to File a Claim

Out-of-Network Chiropractic Claim Form

Out-of-Network Vision Claim Form

Coordination of Benefits Information

File an appeal about a coverage decision for Part C medical services or items

File a complaint with Optima Medicare

Members Appeals Packet

Members Complaints Packet (Family Care)

Members Complaints Packet (Family Care)

File an appeal for medical items or services for Optima Community Complete (HMO D-SNP)

File a complaint with Optima Community Complete (HMO D-SNP)

Optima Community Complete Appeals

Optima Community Complete Request for Drug Coverage Determination

Request a Redetermination (appeal) for a Optima Community Complete (HMO D-SNP) Prescription Drug

Optima Medicare Rx (PDP) Coverage Determination Request

Optima Medicare Rx (PDP) Coverage Redetermination Request

Request a standard decision for Medicare Part D (prescription drugs)

Request for Medicare Prescription Drug Coverage Redetermination

2023 Medicare Home Delivery Prescription Drug Form

Mail Order Frequently Asked Questions

Mail Order Pharmacy Privacy Notice

Mirena Eligibility Form

Mirena Order Form

Proprium Pharmacy Frequently Asked Questions

Sentara Home Infusion Pharmacy Request Form for Injectables

Specialty Pharmacy FAQs (Proprium Pharmacy)

2022 English & Spanish Medicare Member Reimbursement Form

2023 Commercial and Medicaid Member Reimbursement Form

2023 Medicare Member Reimbursement Form

2023 Medicaid Member Reimbursement Form

2023 Medicare Member Reimbursement Form (Spanish)

Instructions for Pharmacy Reimbursement

Optima Community Complete Request for Drug Coverage Determination

Part D Redetermination Request (Appeal) Form

Transitioning Care to Sentara Health Plans