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 form prepared by the Center for Medicare & Medicaid Services (CMS) in English or Español.

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.

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 $45 every three months for non-prescription drug store purchases.


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Last Updated: 1/3/17