Member Forms

Member Forms

Below is a list of Boston Medical Center HealthNet Plan Senior Care Options program forms.

Drug Coverage Determination Request Form — Request approval of a prescription drug that is not covered or has restrictions.

Request for Redetermination of Medicare Prescription Drug Denial Form — Appeal a decision about drug coverage that you do not agree with.

Prescription Reimbursement Form — Request reimbursement for a prescription that you paid for out-of-pocket.

Reimbursement Request Form — Request reimbursement for any medical expenses you may have paid for out-of-pocket.
PCP Selection Form — Select or change your Primary Care Provider (PCP).

Appointing a Representative — Name someone you know and trust to communicate with our plan on your behalf (for example, to submit requests or file appeals for you). Or complete this Appointing a Representative form (Nombramiento de un Representante) prepared by the Center for Medicare & Medicaid Services (CMS) .

Revocation of Personal Representative Form — Remove a personal representative from your healthcare decisions.

Healthcare Proxy Form — Name someone to make decisions about your medical care if you can no longer speak for yourself. This form is prepared by Massachusetts Health Decisions.

PHI Permissions for Use Form — Let us share your Protected Health Information (PHI) with those who need it to provide healthcare services to you.

Release of Information Form - Request that we share your information with a third party

Additional Benefits

Weight Watchers® Reimbursement Form — Get reimbursed for your Weight Watchers® membership (total cost of up to a 13-week membership per year).

Fitness Reimbursement Form — Get reimbursed for your fitness class or club (up to $150 per year).

Healthy Rewards Over-the-Counter Reimbursement Form — Get $80 every three months for non-prescription drug store purchases.


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Last Updated: 5/21/18