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Materials and Forms

2025 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), RxMax (HMO), Platino Ideal (HMO D-SNP), Platino Progreso (HMO D-SNP), Platino MásCa$h (HMO D-SNP), Platino Total (HMO D-SNP), Platino Máximo (HMO D-SNP), y Planes de Salud Grupales (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

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

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