Forms

General

Need a form? Here you'll find a list of the most common forms associated with each type of Medicare plan.

Whether you are enrolled in a Regence Medicare Advantage Plan, a Regence Medigap (Medicare Supplement) Plan or a Medicare Part D Stand-Alone Plan offered by one of our affiliates, you can quickly and easily locate the forms you need.

Medicare Advantage

Below are the forms most commonly needed by Medicare Advantage plan members.

If you do not find the Medicare form you are looking for in this section, please contact our office at 1 (800) 541-8981. Our telephone hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711.

General Medicare Advantage Plans Forms
Use this form to set up automatic payment of premium from your personal bank account for Regence Medicare Advantage (PPO) plans.
Authorization for to disclose health information to a designated party for a specific purpose.
Application Form for Regence MedAdvantage (PPO) Plans
 Use this form to apply for Regence MedAdvantage (PPO) coverage. Enrollment is subject to eligibility and enrollment or election periods.
Coverage Determination Form (Members and Providers) Use this form for Rx coverage decisions.
Prescription Forms
(PDF) Prescription Claim Form Use this form to submit for reimbursement of covered medications you may have purchased without using your member card.
(PDF) Postal Prescription Services Use this form for mail order prescriptions from Postal Prescription Services.
(PDF) Walgreens Mail Service Brochure Walgreens offers fully integrated retail and mail service with convenient delivery to your home or office.

(PDF) Walgreens Member Registration and Mail Service Order Form

 Use this form to register and submit your first prescription order to Walgreens Mail Service.
(PDF) Walgreens Mail Service Prescriber Fax Form Use this form for submitting Walgreens mail-order prescriptions. The form must be faxed from a prescriber's office to be valid.
Grievance and Appeals Forms
(Fillable PDF) Appeal Form for Medical Use this form to request an appeal to a medical coverage decision.
Appeal Form for Prescription
(PDF) Regence MedAdvantage + Rx Classic
(PDF) Regence MedAdvantage + Rx Enhanced		 Use this form to request an appeal to a prescription coverage decision.
(Fillable PDF) Complaint Form Use this form to file a complaint/grievance with us.
(PDF) Appointment of Representative Use this form to appoint another individual to act on your behalf.

Part D

Part D:

Medicare Part D plans offer stand-alone prescription drug coverage. Anybody who is enrolled in Original Medicare (Parts A and/or B) is eligible to enroll in Part D. Anybody enrolled in a Medigap plan can enroll as well.

Shop & Compare Part D Plans

Learn more about Medicare Part D stand-alone prescription drug coverage:


Forms:

2013.

Medigap

Below are forms for Regence Bridge Medigap plans. If you do not find the forms you are looking for, please call us.

Medigap (Medicare Supplement) Plans Forms Description
Application Form for Regence Bridge Medigap Plans
 Use this form to apply for Regence Bridge Medigap coverage. (Optional) Fill out the Surepay section of this form to set up automatic payment of premium from your personal bank account.

Note: To print a PDF document, you need Adobe® Acrobat® Reader. Download it now for free. 

Last updated 12/27/2012
Y0062_2013_V3_MEDICARE_ADVANTAGE_AND_SCRIPT Approved