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Asuris Medicare Script and Asuris Medicare Script Enhanced


Forms

Resource
Description
General Forms
Application Form
• 2010 (68k PDF)
 Use this form to apply for Asuris Medicare Script (PDP) coverage. Enrollment is subject to eligibility and enrollment or election periods.
Authorization for Use and Disclosure of Protected Health Information (43k) Authorization for Asuris to disclose health information to a designated party for a specific purpose.
Prescription Claim Form (62k PDF) Use this form to submit for reimbursement of covered medications you may have purchased without using your member card.
Surepay Information and Authorization Form
• 2010 (39k)		 Use this form to set up automatic payment of premium from your personal bank account.
Prescription Mail Order Form
Postal Prescription Services (31k PDF)
Use this form for mail order prescriptions from Postal Prescription Services.
Grievance and Appeals Forms
Coverage Determination Form - Members Members: Use this form for coverage decisions.
Coverage Determination Form - Providers Providers: Use this form for coverage decisions.
Appeal Form (28k) Use this form to request an appeal to a coverage decision.
Complaint Form (29k) Use this form to file a complaint/grievance with us.
Appointment of Representative Use this form to appoint another individual to act on your behalf.

Last updated 01/01/2010

C0001_2010 WEB ASURIS MEDICARE SCRIPT FORMS 10/2009

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