Our Plans Forms | Medicare | Health First Health Plans

Member Forms

For assistance with any of these forms, please contact customer service.

Mail order form — for filling new prescriptions from Health First Family Pharmacy (for more information, visit Health First Family Pharmacy). You must use MedVantx if you need your drugs shipped outside of Florida.
Request for Medicare Prescription Drug Coverage Determination — if a drug requires prior authorization or an exception, your doctor should submit this form with applicable medical information to our Pharmacy Team for consideration.
Medical Authorization Request Form — for your physician to request authorization for a medical service
Hospice pharmacy authorization request form — if there is a question as to whether a drug should be covered under your prescription drug benefit (Part D) or hospice benefit, you or your doctor can submit this form to our Pharmacy Team for a coverage determination.
Request for Redetermination of Medicare Prescription Drug Denial — for members

Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it
Medical reimbursement form — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services

Please send completed form(s) below to:
Health First Health Plans
6450 US Highway 1
Rockledge, Florida 32955

Enrollment Request Form 2021 | 2020 — use this form if you will be joining our Medicare Advantage plan.
Disenrollment form — for current members to change from one of our plan options to another.
Plan selection form 2021 | 2020 — for current members to change from one of our plan options to another (for example, change from Value to Classic)
Appointment of representation form — if you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle appeals and grievances with us on your behalf
Authorization to disclose your Protected Health Information (PHI) form — if you want to give someone permission to access your personal health information (for example claims, medical, or financial information)

Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.

Y0089_EL8540M | Accepted date: 10/01/2020
Last updated: 01/13/2021