Let us help you: 1 (888) 734-3623
Medicare Forms
Below are the forms most commonly needed by Medicare plan members. If you do not find the Medicare form you are looking for in this section, please call customer service at 1 (800) 541-8981 from 8 a.m. to 8 p.m., Pacific time, seven days a week. TTY users should call 711.
| Medicare Member Forms | Description |
|---|---|
| General Forms | |
| SurePay Information and Authorization Form • 2008 (72k PDF) • 2009 (37k PDF) |
Use this form to set up automatic payment of premium from your personal account for Regence MedAdvantage and Preferred Choice Sixty-Five plans. |
| Prescription Claim Form (62k PDF) | Use this form to submit for reimbursement of covered medications you may have purchased without using your member card. |
| Authorization for Use and Disclosure of Protected Health Information (55k PDF) | Authorization for Regence BlueCross BlueShield of Oregon to disclose health information to a designated party for a specific purpose. |
| Application Form for Regence MedAdvantage Plans • 2008 (57k PDF) • 2009 (63k PDF) |
Use this form to apply for Regence MedAdvantage coverage. Enrollment is subject to eligibility and enrollment or election periods. |
| Short Application Form for Regence MedAdvantage Plans • 2008 (33k PDF) • 2009 (33k PDF) |
Existing members may use this form to upgrade their plan. |
| Prescription Mail-Order Forms | |
| Postal Prescription Services (30k PDF) | Use this form for mail order prescriptions from Postal Prescription Services. |
| Walgreens Mail Service (57k PDF) | Use this form for mail order prescriptions from Walgreens Mail Service. |
| Walgreens Prescription Fax Order Form (31k PDF) | Use this form if you would like prescriptions faxed to Walgreens. Print this form and bring it to your doctor. |
| Grievance and Appeals Forms | |
| Coverage Determination Form (102k PDF) | Use this form for coverage determinations. |
| Appeal Form (30k PDF) | Use this form to request an appeal to a coverage determination. |
| Complaint Form (30k PDF) | Use this form to file a complaint/grievance with us. |
| Appointment of Representative (67k PDF) | Use this form to appoint another individual to act on your behalf. |
