- plan documents
- 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.
Appointment of Representative
Need a friend, family member, or someone else you trust to handle an appeal or complaint? You'll 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.
Medicare has rules about when you can leave your plan — and what happens when you do.
Join a Devoted Health HMO plan or HMO Prime plan.
Use this form if you want to switch to a different Devoted plan. Note that this isn't an enrollment form. You can use it only when you already have a Devoted plan, and you want to switch to one of our other plans.
Usually, your provider takes care of prior authorizations. But you can ask for one yourself.
Prescription Drug Forms
Medicare Prescription Drug Coverage Determination
Use this form when you want to ask for a coverage determination about a prescription drug.
Redetermination of Medicare Prescription Drug Denial Form
Use this form when you want to appeal a coverage determination about a prescription drug.
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.