Forms

Forms for authorizations, appeals, enrollment and member requests.

Plan Year

State

Language

Plan Name

On this page

Appointment of Representative (Spanish)

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Appointment of Representative (English)

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Best Available Evidence Form

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Verification of Chronic Condition Form (English)

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Medicare Prescription Payment Plan Form (Spanish)

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Medicare Prescription Payment Plan Form (English)

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Authorization Service Request (Spanish)

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Authorization Service Request (English)

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Authorization for Disclosure of Protected Health Information (Spanish)

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Authorization for Disclosure of Protected Health Information (English)

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MedImpact Direct Mail Order Prescription Drug Forms (English)

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Prescription Drug Claim Form (Spanish)

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Prescription Drug Claim Form (English)

To submit a Healthcare Claim or Bill, please complete the form and submit the form and receipt(s) to: MedImpact Healthcare Systems, Inc. PO Box 509108 San Diego, CA 92150-9108 Fax: 858-549-1569 E-mail: Claims@Medimpact.com

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Complaint & Appeal Form (Spanish)

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Complaint & Appeal Form (English)

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