Asuris Medicare Script Forms

Asuris Medicare Script Basic &
Asuris Medicare Script Enhanced

Forms

Resource	Description
General Forms
Application Form for Asuris Medicare Script • 2012	Use this form to apply for Asuris Medicare Script coverage. Enrollment is subject to eligibility and enrollment or election periods. Medicare beneficiaries may enroll in Asuris Medicare Script through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
Authorization for Use and Disclosure of Protected Health Information	Authorization for Asuris to disclose health information to a designated party for a specific purpose.
Surepay Information and Authorization Form • 2012	Use this form to set up automatic payment of premium from your personal bank account.
Coverage Determination Form - Members	Members: Use this form for coverage decisions.
Coverage Determination Form - Providers	Providers: Use this form for coverage decisions.
Prescription Forms
Prescription Claim Form (PDF)	Use this form to submit for reimbursement of covered medications you may have purchased without using your member card.
Postal Prescription Services (PDF)	Use this form for mail-order prescriptions from Postal Prescription Services.
Grievance and Appeals Forms
Appeal Form • Asuris Medicare Script Basic • Asuris Medicare Script Enhanced	Use this form to request an appeal to a coverage decision.
Complaint Form	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 1/27/2012
Pending CMS Approval
Y0062_2012_MEDICARE_ADVANTAGE_AND_SCRIPT CMS APPROVED MMDDYYYY

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