Member Forms
For assistance with any of these forms, please contact customer service.
Prescriptions/pharmacy/authorizations
- 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
Claims
- 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
Other
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