Forms Massachusetts

Commonly Requested Forms

Appointment of Representative Form* — (For use with organizational determinations, appeals and grievances ONLY)
LIS 2019 Premium Summary Chart (PDF)
LIS 2020 Premium Summary Chart (PDF).
Authorization to Release Personal Health Information to a Friend or Family Member (PDF)
Health Care Proxy (PDF)
Download the Senior Whole Health Medicare Advantage & Senior Care Options (SCO) Enrollment Application (PDF)
Download the Senior Whole Health Senior Care Options (SCO) Enrollment Application (PDF)

Medicare Forms

Medicare Complaint Form*

Online Request for Medicare Part D Redetermination
Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF)

Online Request for Medicare Part D Prescription Drug Coverage Determination 

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in ENGLISH

Medicare Reconsideration Request Form (PDF)   

Prior Authorization Forms

Drug Coverage Determination Form (PDF) in ENGLISH

Download the Senior Whole Health 2019 Prior Authorization Criteria (PDF) — Effective December 1, 2019

Download the Senior Whole Health 2020 Prior Authorization Criteria (PDF).

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Last Updated 12/01/2019