Ir al contenido
Navigated to Member Forms page

Member Forms


If you're looking for a form, you'll find it here. And if you can't, give us a call at 1-800-DEVOTED (1-800-338-6833), TTY 711.

Personal Forms

Advance Medical Directive
You fill out this form just in case something happens to you and you can't make decisions for yourself.

Learn about Advance Medical Directives

Appointment of Representative
Need a friend, family member, or someone else you trust to handle an appeal or complaint? First you need to appoint (name) them as your representative.

Learn about Appointing a Representative

Consent for Release of Protected Health Information (PHI)
Fill out this form when you want to give us the OK to share your health information with someone you trust.

English | Spanish | Creole

Health Care Surrogate
Use this form to allow someone you trust to make healthcare decisions for you — in case you can't do it for yourself.

View Health Care Surrogate Form

Once you've complete a health care surrogate form, you can send us a copy to keep in your records. You can fax it to 1-877-234-9988.

Or mail it to:
Devoted Health, Inc.
PO Box 540279
Waltham, MA  02454

Plan Forms

Disenrollment
Medicare has rules about when you can leave your plan — and what happens when you do.

Learn about Disenrollment

Enrollment
Join a Devoted Health HMO plan or HMO Prime plan.
English | Spanish | Creole

Prior Authorization
Usually, your provider takes care of prior authorizations. But you can ask for one yourself.

View Prior Authorization Form

Prescription Drug Forms

Request a Medicare Prescription Drug Coverage Determination
Use this form when you want to ask for a coverage determination about a prescription drug.

View Coverage Determination Form (Link coming soon.)

Request for Redetermination of Medicare Prescription Drug Denial Form
Use this form when you want to appeal a coverage determination about a prescription drug.

View Coverage Redetermination Form (Link coming soon.)

Request for Reconsideration of Medicare Prescription Drug Denial Form
Use this form when you want to make a second appeal on a coverage determination about a prescription drug.

View Coverage Reconsideration Form (Link coming soon.)