Member Forms

• 2020 Harvard Pilgrim Stride Enrollment Form
• Pre-Enrollment Checklist (pdf)
• OptumRx Home Delivery Prescription Drug Order Form (PDF)
• Prescription Drug Reimbursement Forms:
  • MedImpact Reimbursement Form (pdf) (for claims from 2019 and earlier)
  • OptumRx Reimbursement Form (pdf) (for claims from 2020)
• Part D (Pharmacy) Coverage Determination Request Form
• Part D Redetermination Request Form
• Electronic Funds Transfer (EFT) Form (pdf)
• Member Reimbursement Form (pdf) - effective 1/1/2020
• Designation of Representative Form (pdf)
• CMS Appointment of Representative form (pdf)
• Authorization to Release Information Form
• New Member Presentation Massachusetts
• New Member Presentation Maine
• New Member Presentation New Hampshire

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.

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Last updated: 1/3/2020