Documents and Forms
If you need assistance or if you want copies of any of the below forms, give us a call at:
Toll-Free: 1-833-342-7463, TTY 711.
We are open 7 days a week, 8:00 a.m. to 8:00 p.m.
- Advance Care Planning:
- You have access to an online advance care planning resource called, MyDirectives® (https://mydirectives.com/). This resource guides you to create an advance directive where you can combine the elements of:
a) A Living Will- What’s important to you! To include medical treatment goals and last wishes.
b) Medical power of attorney-appointment of the person or persons whom you would like to make medical treatment decision on your behalf.
c) Expression of treatment wishes and desires.
d) Decisions on Organ donation form.
- You have access to an online advance care planning resource called, MyDirectives® (https://mydirectives.com/). This resource guides you to create an advance directive where you can combine the elements of:
- Advance Directives – English / Spanish
- Appeals Part C Form – English / Spanish
- Appointment of Representative (AOR) – English / Spanish
- Authorization for Release of Information – English / Spanish
- Authorization for Release of Information – Discontinuation Form – English / Spanish
- Enrollment Form English / Spanish
- Member Grievance Form English / Spanish
- Health Risk Assessment English / Spanish
- Member Rights and Responsibilities English / Spanish
- Prior Authorization/Organization Determination Form English / Spanish
- Request for Reimbursement Medical Benefits English / Spanish
- Star Rating Information 2024 English / Spanish
Prescription Drug Forms
- Prescription Drug Coverage Request Form – English / Spanish
- Prescription Drug Appeals Form – English / Spanish
- Prescription Drug Mail Order – English / Spanish
- Transition Policy – English / Spanish
- Prescription Drug Reimbursement Form – English / Spanish
Privacy
H4140_WSMEMDOCFORM_C
Last updated: 01/31/2024
