Forms

Find the forms you need quickly and easily.

Appointment of Representative (AOR) Form

Appoint someone to act on your behalf for an appeal or grievance

Medicare.gov Complaint Form

Use this form to file a complaint with Medicare

Enrollment Form

Apply for enrollment in a MedCare Partners Health Plan of Texas plan

Grievance and Appeal Form

Submit a complaint or request an appeal

Prior Authorization Form

Request prior authorization for a medical service

Direct Member Reimbursement (DMR) Form

Submit receipts for reimbursement

Special Supplemental Benefits for the Chronically Ill (SSBCI) Eligibility Form

Form used to verify a qualifying chronic condition for enrollment in a C-SNP plan

Consent to Verbally Share PHI

Complete this form to allow us to share PHI with someone you designate

Health Risk Assessment

Use this form to complete your HRA

Prior Authorization Form

Request prior authorization for a medical service

Exception Request Form / Part D Coverage Determination Form

Request a Part D exception

Part D Redetermination Form

Request a Part D redetermination

Scope of Appointment (SOA)

Enrollment Form

Health Risk Assessment

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Forms

Appointment of Representative (AOR) Form

Medicare.gov Complaint Form

Enrollment Form

Grievance and Appeal Form

Prior Authorization Form

Direct Member Reimbursement (DMR) Form

Special Supplemental Benefits for the Chronically Ill (SSBCI) Eligibility Form

Consent to Verbally Share PHI

Health Risk Assessment

Prior Authorization Form

Exception Request Form / Part D Coverage Determination Form

Part D Redetermination Form

Scope of Appointment (SOA)

Enrollment Form

Health Risk Assessment

Can't Find What You Need?

1-866-MCP-TX01 (1-866-627-8901)

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1-866-MCP-TX01
(1-866-627-8901)