Our Plans Forms | Medicare | Health First Health Plans

Member Forms

For assistance with any of these forms, please contact our Care Team.

Mail order form — for filling new prescriptions from Health First Family Pharmacy (for more information, visit Health First Family Pharmacy).
2021 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. 2022 form coming soon.
2021 Medical Authorization Request Form — for your physician to request authorization for a medical service
2021 Request for Redetermination of Medicare Prescription Drug Denial — for members. 2022 form coming soon.

Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it
2021 Medical reimbursement form — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services
2022 Medical reimbursement form

Please send completed form(s) below to the address found on each form.

Enrollment Request Form 2022 — 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 2022 — 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. Once complete, please return this form to:
Health First Health Plans
MA Grievance and Appeal Communications
PO Box 62378
Phoenix, AZ, 85082
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_EL9653_M | Accepted date: 10/01/2021
Last updated: 12/30/2021