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.
Advance Medical Directive
You fill out this form just in case something happens to you and you can't make decisions for yourself.
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.
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.
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.
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
Medicare has rules about when you can leave your plan — and what happens when you do.
Usually, your provider takes care of prior authorizations. But you can ask for one yourself.
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.
(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.)