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Regence Life and Health (RLH) Medicare Script™
and RLH Medicare Script™ Enhanced
 

Forms

Resource
Description
General Forms

Application Form

Idaho
• 2008 (30k PDF)
• 2009 (57k PDF)

Utah
• 2008 (30k PDF)
• 2009 (57k PDF)

 Use this form to apply for Regence Life and Health Medicare Script coverage. Enrollment is subject to eligibility and enrollment or election periods.
Authorization for Use and Disclosure of Protected Health Information
• Idaho (57k PDF)
• Utah (15k PDF)		 Authorization for Regence Blue Shield of Idaho or Regence BlueCross BlueShield of Utah to disclose health information to a designated party for a specific purpose.
Prescription Claim Form (62k PDF) Use this form to submit for reimbursement of covered medications you may have purchased without using your member card. For both Idaho and Utah.
SurePay Information and Authorization Form
• 2008 (132k PDF)
• 2009 (30k PDF)
Use this form to set up automatic payment of premium from your personal account. For both Idaho and Utah.
Mail Order Forms
Postal Prescription Services (31k PDF)
Use this form for requesting mail order prescriptions from Postal Prescription Services.
Walgreens Mail Service (43k PDF) Use this form for requesting mail order prescriptions from Walgreens Mail Service.
Walgreens Prescription Fax Order Form (34k 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 requesting 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.

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