Forms

Pharmacy forms

• Coverage Determination (exception) Request Form (PDF)
• Over-the-counter (OTC) catalog and order form (PDF)
• Prescription Claim Form (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.
• Disenrollment Form (PDF)
• Attestation of Disenrollment Form (PDF) 
• 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.