Forms

Counties Served:

California: Fresno, Los Angeles, Madera, Orange, Riverside, San Bernardino, and San Diego (New for 2025: Kern & Imperial)
Nevada: Churchill, Clark, Carson City, and Washoe

Select your state:

California

Authorization Service Request

Complaint & Appeal Form

Appointment of Representation

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Covered Medication List (Formulary)

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

Medicare Prescription Payment Plan Form

Nevada

Authorization Service Request

Complaint & Appeal Form

Appointment of Representation

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Covered Medication List (Formulary)

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

Medicare Prescription Payment Plan Form

Counties Served:

California: Fresno, Imperial, Kern, Los Angeles, Madera, Orange, Riverside, San Bernardino, and San Diego
Nevada: Churchill, Clark, Carson City, and Washoe

Select your Year and State:

California

Authorization Service Request

Complaint & Appeal Form

Appointment of Representative

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Formulary (List of Covered Drugs)

Note: Formulary (List of Covered Drugs) Form is updated on a monthly basis.

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

Dental Fee Schedule

Medicare Prescription Payment Plan Form

Verification of Chronic Condition Form

Nevada

Authorization Service Request

Complaint & Appeal Form

Appointment of Representative

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Formulary (List of Covered Drugs)

Note: Formulary (List of Covered Drugs) Form is updated on a monthly basis.

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

Dental Fee Schedule

Medicare Prescription Payment Plan Form

Verification of Chronic Condition Form

California

Authorization Service Request

Complaint & Appeal Form

Appointment of Representation

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Covered Medication List (Formulary)

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

Medicare Prescription Payment Plan Form

Nevada

Authorization Service Request

Complaint & Appeal Form

Appointment of Representation

Authorization for Disclosure of Protected Health Information

Enrollment Form

MedImpact Direct Mail Order Prescription Drug Forms

Covered Medication List (Formulary)

Prescription Drug Claim Form

Health Risk Assessment

Bridge Case Management Form

Transportation Reimbursement Form

Scope of Appointment Form

Medicare Prescription Payment Plan Form

This page was last updated on 12/01/2025. Pending CMS approval.