Counties Served:

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

Select your state:



Authorization Service Request

Complaint & Appeal Form

Appointment of Representation

Authorization for Disclosure of Protected Health Information

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

This page was last updated on 2/16/24. Pending CMS approval.