Forms

Pharmacy forms

• Coverage Determination (exception) Request Form PDF
• Over-the-counter (OTC) catalog and order form PDF
• Personal Medication List PDF January 18, 2023
• Prescription Claim Form PDF
• Recommended To-Do List PDF January 18, 2023
• 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.