Form

Description

Asuris TruAdvantage Plans SurePay Information and Authorization Form (PDF)

Use this form to set up automatic payment of premium from your personal account.

Prescription Claim Form (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

Authorization for Asuris and/or a member's health care provider(s) to disclose health information to a designated party for a specific purpose.

Asuris TruAdvantage Plans Application Form

Use this form to apply for coverage. Enrollment is subject to eligibility and enrollment or election periods.

Postal Prescription Services (PDF)

Use this form for requesting mail order prescriptions from Postal Prescription Services.

Walgreens Mail Service (PDF)

Use this form for requesting mail order prescriptions from Walgreens Mail Service.

Walgreens Prescription Fax Order Form (PDF)

Use this form if you would like prescriptions faxed to Walgreens. Print this form and bring it to your doctor.

Coverage Determination Form (PDF)

Use this form for requesting coverage determinations.

Appeal Form (PDF)

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

Complaint Form (PDF)

Use this form to file a complaint/grievance with us.

Appointment of Representative (PDF)

Use this form to appoint another individual to act on your behalf.