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Asuris Northwest Health serves Yakima, Walla Walla and other communities in Eastern Washington with affordable medical and dental insurance plans.
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Asuris TruAdvantage (PPO)

Asuris TruAdvantage
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Medicare Forms

Below are the forms most commonly needed by Medicare plan members. The forms on this page are for our Medicare Advantage plans. Please click here for forms for our Medigap plans.

If you do not find the Medicare form you are looking for in this section, please contact our office at 1-800-541-8981. TTY users should call 711. From November 15 through March 1 our telephone hours are 8 a.m. to 8 p.m. seven days a week. After March 1 our telephone hours are 8 a.m. to 8 p.m., Monday through Friday, and you may leave a message on Saturdays, Sundays and holidays. We will return your call on the next business day.

Medicare Advantage and Part D Forms

Form

Description

GENERAL FORMS
SurePay Information and Authorization Form
2010 (42k PDF)

Use this form to set up automatic payment of premium from your personal bank account for Asuris TruAdvantage (PPO) plans.

Prescription Claim Form (62k PDF)

Use this form to submit for reimbursement of covered medications you may have purchased without using your member card.

Authorization for Use and Disclosure of Protected Health Information (43k)

Authorization for Asuris Northwest Health to disclose health information to a designated party for a specific purpose.

Application Form for Asuris TruAdvantage (PPO) plans
2010 (79k PDF)

Use this form to apply for Asuris TruAdvantage (PPO) coverage. Enrollment is subject to eligibility and enrollment or election periods.

Short Enrollment Form for Asuris TruAdvantage (PPO)
2010 (79k PDF)

For members upgrading their plan. All pages of this form must be given to inquiring or applying individuals.

PRESCRIPTION MAIL ORDER FORM

Postal Prescription Services (30k 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 requesting coverage decisions.

Coverage Determination Form (Providers) Providers: Use this form for requesting coverage decisions.

Appeal Form (30k)

Use this form to request an appeal to a coverage decision.

Complaint Form (30k)

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.

Below are forms for Asuris Pledge Medigap plans. If you do not find the forms you are looking for, please call us at 1-888-734-3623 from 8 a.m. to 5 p.m., Monday through Friday, Pacific time.

Medigap (Medicare Supplement) Forms

Form

Description

Application Form for Asuris Pledge Medigap plans
2010 (PDF)

Use this form to apply for Asuris Pledge Medigap coverage. (Optional) Fill out the Surepay section of this form to set up automatic payment of premium from your personal bank account.

Last updated 05/01/2010
CMS Approval: M0016_2010 WEB MA FORMS 10/2009

 

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