Regence Life and Health logo
  « 2009 coverage page
 
  « 2010 coverage page

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

Forms

Resource
Description
General Forms

Application Form

Idaho
• 2009 (57k Fillable PDF)
• 2010 (72k PDF)

Utah
• 2009 (57k Fillable PDF)
• 2010 (72k PDF)

 Use this form to apply for Regence Life and Health Medicare Script (PDP) 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 BlueShield 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
• 2009 (30k PDF)
• 2010 (39k PDF)		 Use this form to set up automatic payment of premium from your personal bank account. For both Idaho and Utah.
Prescription Mail Order Form
Postal Prescription Services (31k PDF)
Use this form for requesting mail order prescriptions from Postal Prescription Services.
Grievance and Appeals Forms
Coverage Determination Form - Members Members: Use this form for requesting coverage decisions.
Coverage Determination Form - Providers

Providers: Use this form for requesting coverage decisions.
Appeal Form (30k PDF) Use this form to request an appeal to a coverage decision.
Complaint Form (30k PDF) Use this form to file a complaint/grievance with us.
Appointment of Representative Use this form to appoint another individual to act on your behalf.

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

Last updated 10/1/2009
C0001_2010 WEB RLH MEDICARE SCRIPT FORMS 10/2009
 
©2009 Regence Life and Health Insurance Company. All rights reserved.
Ethics  Privacy  Fraud  Feedback