Member Forms

Legal

• Release of Information Form. Use this form to allow loved ones to access your protected health information.
• CMS Appointment of Representative Form. Use this form to appoint someone to represent you on formal matters, such as appeals or grievances.
• Connecticut Advanced Directive. Use this form to authorize someone to act on your behalf for private, health-related decisions or legal matters. 
• VA Release of Information Form. Use this form to authorize the Department of Veterans Affairs to release health-related information to those you designate.

Prescription Drugs

• CVS Caremark Prescription Mail Order Form. Use this form to start mail-order pharmacy services.
• Request for Medicare Prescription Drug Coverage Determination. Use this form to request a coverage determination or exception to MediGold’s drug formulary.
• Request for Redetermination of Medicare Prescription Drug Denial. Use this form to file an appeal related to your Part D prescription drug benefits.

Prior Authorization

• Prior Authorization Form. You or your provider can use this form to request prior authorization for services that require it.

Reimbursement

• CVS Caremark Drug Claim Form. Use this form to be reimbursed for out-of-pocket covered prescription medication.
• Direct Member Reimbursement Request Form. Use this form to request reimbursement for glasses after cataract surgery or other allowable medical expenses.