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Member Forms

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


Prescriptions/pharmacy/authorizations

Claims

Other

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