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Materials and Forms 2024

2024 Materials and Forms

In order to help you find all materials needed to learn about our products, we designed this exclusive section. For full information of each form, please refer to their individual sections.

Evidence of Coverage

Summary of Benefit

Annual Notice of Changes​

Durable Medical Equipment Formulary

Providers Directory

Providers Search tool
Providers and Pharmacies Directory

Providers and Pharmacies Directory applies to: Efectivo (HMO), Essential (HMO-POS), Patriot (HMO), Primero (HMO C-SNP), Firme (HMO), En Tu Hogar (HMO), Hero (HMO), Metro (HMO), InteliCare (HMO), Exacto (HMO), Excede (HMO), Del Caribe (HMO), Platino Ideal (HMO D-SNP), Platino Progreso (HMO D-SNP), Platino MásCa$h (HMO D-SNP), PlatinoTotal (HMO D-SNP), Platino Máximo (HMO D-SNP), Platino Del Sur (HMO D-SNP) and Group Health Plans (HMO-POS)

Authorization for use and/or disclosure of protected health information
Request for access to your protected health information
Request for accounting of disclosures
Request to amend protected health information
Request for Confidential Communications
Privacy complaint form
Request for the restriction of use and/or disclosure of protected health information
Request to revoke my authorization for use and or Disclosure of protected health information
Request for termination of a restriction for use and or Disclosure of protected health information
Automatic Discount Request Form (ACH)
Grievances Submission Form
Appeals Request Form
Request for Appointment of Representative
Pre Certification Request Formulary
Direct Member Reimbursement Form - Pharmacy
Medical Expenses Reimbursement form
Reimbursement form for over the counter items (OTC) form
Request for Determination of Medicare Prescription Drug
Request for Hospice Information for Medicare Part D Form
Part D late enrollment penalty reconsideration request
Request for Reconsideration of Medicare Prescription Drug Denial form
Request for Redetermination of Medicare Prescription Drug Denial
Registration and Prescription Mail Order Form
Authorization for Use of Home Bundle Benefit
Request for revocation of my authorization to use the home bundle benefit​

Medicare New Benefits

Multi-language Interpreter Services

MCS Classicare is a product underwritten by MCS Advantage, Inc. MCS Classicare is an HMO plan with a Medicare contract and a contract with the Medicaid program in Puerto Rico. Enrollment in MCS Classicare depends on contract renewal. MCS Advantage, Inc. complies with federal civil rights laws applica​ble and does not discriminate on grounds of race, color, national origin, age, disability or sex. MCS Advantage, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. MCS Advantage, Inc. 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。 This information is not a complete description of benefits. Call ​1.866.627.8183 (TTY: 1.866.627.8182) for more information. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1.866.627.8183 (TTY: 1.866.627.8182). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.866.627.8183 (TTY: 1.866.627.8182). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1.866.627.8183（TTY: 1.866.627.8182). Medicare beneficiaries may also enroll in MCS Classicare through the CMS Medicare Online Enrollment Center located at www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system.​ Multilingual Interpreti​ng Services.​ Learn more about our service area listing.​
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