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Form Name Description
Coverage Determination Request Form
Submitted to request that we cover a prescription not currently included in the plan in which a member is enrolled. A doctor typically fills this out for the member.
Appointment of Representative
**See below for instructions on how to appoint a representative
Used to appoint any individual, including an attorney, to represent a member during the processing of a claim or claims, and/or any subsequent appeal or in connection with any aspect of dealing with an insurance provider.
Member Appeal Request form
Filed when you do not agree with a decision made by us regarding a request for coverage or payment of service you requested.
Member Grievance Request Form
Filed when you have a complaint about service received from one of our network providers, such as a pharmacy or doctor.
COB - Direct Claim Form
(Optum Form)
Mail Order Form
(Optum Form)

**Appoint a representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, fill out the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must mail the signed form to the Member Services Department at PO Box 56-5748, Miami, FL 33256.