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Member Forms


If you're looking for a form, you'll find it here. And if you can't, give us a call at 1-800-DEVOTED (1-800-338-6833), TTY 711 — or text us at 866-85.

Personal Forms

Advance Care Planning
If you're ever unable to make healthcare decisions for yourself, advance care planning can be a big help to you and your loved ones.

Learn about Advance Care Planning

Appointment of Representative
Need a friend, family member, or someone else you trust to handle an appeal or complaint? You'll need to appoint (name) them as your representative. Learn more about appointing a representative.

Download an AOR form

Consent for Release of Protected Health Information (PHI)
Fill out this form when you want to give us the OK to share your health information with someone you trust. Learn more about sharing PHI.

Fill out a PHI form online

Download a PHI form

Health Risk Assessment (HRA) Form
We ask all new members to fill out this form. It’s a short survey about your health that helps us better match our services to your needs.

View HRA Form

General Reimbursement Form
Use this form to get paid back for things like Wellness Bucks purchases and covered medical services that you paid for yourself. (For any reimbursements related to Part D prescription drugs, use the Prescription Drug Reimbursement form.)

Learn about Reimbursement

Request for Records
Use this form to request copies of your member records.

View Record Request Form

Revoke Personal Documents
Use this form to revoke documents you have on file with us.

View Revoke Documents Form

Plan Forms

Disenrollment
Medicare has rules about when you can leave your plan — and what happens when you do.

Learn about Disenrollment

Enrollment
Join a Devoted Health HMO or PPO plan.

View 2026 Enrollment Form

View 2025 Enrollment Form

Prior Authorization
Usually, your provider takes care of prior authorizations. But you can ask for one yourself.

View 2025 Prior Authorization Form

Prescription Drug Forms

Learn about prescription drug coverage determinations, appeals, and grievances.

Prescription Drug Reimbursement Form
Use this form to get paid back for covered medications you paid for yourself.

View Prescription Drug Reimbursement Form

Medicare Prescription Drug Coverage Determination
Use this form when you want to ask for a coverage determination about a prescription drug.

View Coverage Determination Form

Redetermination of Medicare Prescription Drug Denial Form
Use this form when you want to appeal a coverage determination about a prescription drug.

View Redetermination Form

Reconsideration of Medicare Prescription Drug Denial Form
To make a second appeal on a coverage determination about a prescription drug, choose your state below for the correct form: