Form

Description

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.

Postal Prescription Services (30k PDF)

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

Coverage Determination Form (Members)

Members: 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.

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.