Member Forms

If you're looking for a form, you'll find it here. And if you can't, give us a call at 1-800-DEVOTED (1-800-338-6833), TTY 711 — or text us at 866-85.

Personal Forms

Advance Care Planning
If you're ever unable to make healthcare decisions for yourself, advance care planning can be a big help to you and your loved ones.

Learn about Advance Care Planning

Appointment of Representative
Need a friend, family member, or someone else you trust to handle an appeal or complaint? You'll need to appoint (name) them as your representative.

Learn about Appointing a Representative

Consent for Release of Protected Health Information (PHI)
Fill out this form when you want to give us the OK to share your health information with someone you trust.

View PHI Consent Form

Health Risk Assessment (HRA) Form
We ask all new members to fill out this form. It’s a short survey about your health that helps us better match our services to your needs.

View HRA Form

General Reimbursement Form
Use this form to get paid back for things like Wellness Bucks purchases and covered medical services that you paid for yourself. (For any reimbursements related to Part D prescription drugs, please use the Prescription Drug Reimbursement form below.)

Learn about Reimbursement

Request for Records
Use this form to request copies of your member records.

View Record Request Form

Revoke Personal Documents
Use this form to revoke documents you have on file with us.

View Revoke Documents Form

Plan Forms

Disenrollment
Medicare has rules about when you can leave your plan — and what happens when you do.

Learn about Disenrollment

Enrollment
Join a Devoted Health HMO or PPO plan.

View 2024 Enrollment Form

View 2025 Enrollment Form

Prior Authorization
Usually, your provider takes care of prior authorizations. But you can ask for one yourself.

View 2024 Prior Authorization Form

Prescription Drug Forms

Prescription Drug Reimbursement Form
Use this form to get paid back for covered medications you paid for yourself.

View Prescription Drug Reimbursement Form

Medicare Prescription Drug Coverage Determination
Use this form when you want to ask for a coverage determination about a prescription drug.

View Coverage Determination Form

Redetermination of Medicare Prescription Drug Denial Form
Use this form when you want to appeal a coverage determination about a prescription drug.

View Redetermination Form

Reconsideration of Medicare Prescription Drug Denial Form
Use this form when you want to make a second appeal on a coverage determination about a prescription drug. Choose your state to get the right form:

2024 Forms