Plan Forms
General
Acknowledgement of Receipt/Notice of Privacy Practices
The Acknowledgement of Receipt Notice of Privacy Practices is for you the member or your personal representative to sign and return to Care Improvement Plus acknowledging receipt of the NPP. A member need only sign an acknowledgement one time.
Authorized Representative - Requests may be made by a family member, friend, or other party if the individual demonstrates
legal authority, such as a medical power of attorney. Another way to be delegated this authority is by submitting to the plan a
signed Appointment of Representative form.
For prescription drug determinations, physicians may act on behalf of the beneficiary and do not need the authority just described.
Part B Reimbursement Form
For filing a claim to request payment, use the following form:
Reimbursement Claim Form
Electronic Funds Transfer (EFT) Form
If you would like to have your monthly plan premium automatically deducted from either your checking or savings account,
complete the Electronic Funds Transfer (EFT) Form.
This page was last updated on: 9/9/2011 11:00:46 AM