Miami-Dade > Members Forms

For our members convenience we have included the following forms in Adobe Acrobat PDF format:

• Pre-Enrollment Document
• Appointment of Representative/
  Designation of Healthcare Surrogate Form
• Change of Address Form
• Consent Form
• Instructions About How to Appoint a Representative
• Contact numbers for questions about the Grievance, Coverage Determination, and Appeals process, or to inquire about the status of a Coverage Determination or Appeal request
• Beneficiaries' and Plan's Rights and Responsibilities Upon Disenrollment
• What are Appeals and Grievances?
• How to Obtain an Aggregate Number of Grievances
• Instruction on How to file a Grievance
• Grievance Form
• Medicare Drug Coverage Rights
• Instructions for Completing and Submitting Prior Authorization Form
• Exception Process
• Part D Drug Exception Form
• Instructions for Submitting a Medicare Redetermination Request Form
• Medicare Redetermination Request Form

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