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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 Directives
If you're ever unable to make healthcare decisions for yourself, a living will and a health care surrogate can be a big help to you and your loved ones.

Learn about Advance Directives

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.

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

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

Plan Selection
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.

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

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

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

View Redetermination Form

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 Reconsideration Form