Forms
Resource |
Description |
| General Forms |
Application Form
Idaho
• 2012 (PDF)
Utah
• 2012 (PDF) |
Use this form to apply for Regence Medicare Script coverage. Enrollment is subject to eligibility and enrollment or election periods.
Medicare beneficiaries may enroll in Regence Medicare Script through the CMS Medicare Online Enrollment Center located at www.medicare.gov. |
Authorization for Use and Disclosure of Protected Health Information
• Idaho (PDF)
•
Utah (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. |
Surepay Information and Authorization Form
• 2012 (PDF) |
Use this form to set up automatic payment of premium from your personal bank account. For both Idaho and Utah. |
| Coverage Determination Form - Members |
Members: Use this form for requesting coverage decisions. |
| Coverage Determination Form - Providers |
Providers: Use this form for requesting coverage decisions. |
| Prescription Forms |
Postal Prescription Services (PDF)
|
Use this form for requesting mail order prescriptions from Postal Prescription Services. |
Prescription Claim Form
• 2012 (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. |
| Grievance and Appeals Forms |
Appeal Form
• Regence Medicare Script Basic
• Regence Medicare Script Enhanced |
Use this form to request an appeal to a coverage decision. |
| Complaint Form (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 1/30/2012
Pending CMS Approval
Y0062_2012_MEDICARE_ADVANTAGE_AND_SCRIPT CMS APPROVED MMDDYYYY
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