Enrollment Forms:
Medical benefits:
Pharmacy benefits (including Part D vaccines):
Dental Reimbursement form:
Prescription Drug Forms:
- Part D (Pharmacy) Coverage Determination Request Form
- Part D Redetermination Request Form
- Medicare Part D Reconsideration Form (pdf)
- OptumRx Home Delivery Prescription Drug Order Form (pdf)
- Optum Claim Form Medicare Part D
Billing Form:
Authorization and Appointment of Representative Forms:
- Designation of Representative Form (pdf)
This form will allow a designated representative to receive all information pertaining to your health information and make decisions or changes related to your benefit plan. - Centers for Medicare & Medicaid Services (CMS) Appointment of Representative form (pdf)
This form will allow someone to request a coverage decision or file an appeal or grievance on your behalf. - Personal Representative Cover Form (pdf)
Members may attach their legal personal representative documents with this cover page. - Authorization to Release Information Form
This form will allow an authorized representative to speak to us about your protected health information.
Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in StrideSM (HMO) depends on contract renewal.
Links on this page may take you away from the Harvard Pilgrim Health Care website.
H6750_23036 Last Update: 11/27/2023