Documents

Plan & Coveragepage top | go back

Prescriptions & Paymentspage top | go back

Drug Claims & Alternativespage top | go back

Representative & Confidential InformationRepresentative & Confidential Informationpage top | go back

  • Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
  • Authorization to Release Information - Use this form to provide Protected Health Information (PHI) to a person or organization on your behalf.
  • Confidential Communication Request - Complete this form if you want Basic Blue Rx (PDP) to use a different address when sending member communications including claim related material to you. There may be others involved in your healthcare you may want to contact to make a similar request.
  • Agent of Record Exception Form - Use this form to request a new Agent if a situation arises where you cannot, in good faith, continue business relations with your original Agent. Completing this form does not guarantee a new Agent assignment will be made.
  • Notice of Privacy Practices

General Informationpage top | go back