- plan documents
- 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.
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.
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.
Use this form to get paid back for things like Wellness Bucks purchases and covered services that you paid for yourself.
Medicare has rules about when you can leave your plan — and what happens when you do.
Join a Devoted Health HMO plan.
- 2020 Enrollment Form
- 2021 Enrollment Form for Florida
- 2021 Enrollment Form for Arizona, Ohio, and Texas
Usually, your provider takes care of prior authorizations. But you can ask for one yourself.
Prescription Drug Forms
Medicare Prescription Drug Coverage Determination
Use this form when you want to ask for a coverage determination about a prescription drug.
Redetermination of Medicare Prescription Drug Denial Form
Use this form when you want to appeal a coverage determination about a prescription drug.
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.