2024 Member Forms

PLEASE NOTE: Harvard Pilgrim Health Care will not offer Stride (HMO)/(HMO-POS) Medicare Advantage plans in New Hampshire in 2025. As a result, current members’ coverage will end on December 31, 2024. In addition, the product will no longer be available for new member enrollment effective January 1, 2025. Click here for FAQ

Medical benefits:

• Member Reimbursement Form (pdf)

Pharmacy benefits (including Part D vaccines):

• OptumRx Reimbursement Form (pdf)

Dental Reimbursement form:

• 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

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 Stride^SM (HMO) depends on contract renewal.

Links on this page may take you away from the Harvard Pilgrim Health Care website.

H6750_24007                                                        Last Update: 11/27/2023