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Representative & Confidential Informationpage top | go back

  • Appointing a Representative - You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination, and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
  • Authorization to Release Information - Use this form to provide Protected Health Information (PHI) to a person or organization on your behalf.
  • Confidential Communication Request - Complete this form if you want MedicareBlue Rx (PDP) to use a different address when sending member communications including claim related material to you. There may be others involved in your healthcare you may want to contact to make a similar request.
  • Notice of Privacy Practices

General Informationpage top | go back