MediGold
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Forms

Billing & Payment Forms

Pay your MediGold monthly premium automatically each month through Electronic Funds Transfer.

Online Electronic Funds Transfer Form

Request to have your MediGold monthly premium deducted from your Social Security check.

Social Security Withhold Request Form

Request to stop having your MediGold monthly premium deducted from your Social Security check.

Social Security Withhold Request Termination Form

Claims Forms

If you paid out-of-pocket for covered prescription medication, complete a claim form to get reimbursed for the covered amount of the medication.

CVS Caremark Drug Claim Form

Get reimbursed for glasses needed after cataract surgery.

Post Cataract Lens Reimbursement Form

Enrollment Forms

Enroll in MediGold today, using our convenient online enrollment form!

Online Enrollment Request Form

Are you currently a MediGold member, and you would like to switch from one MediGold plan option to another MediGold plan option? Call Member Services at 1-800-240-3851 (TTY 711), 8 a.m.-8 p.m., 7 days a week, to complete this change request over the phone.

If you are currently a MediGold member, and you would like to disenroll from MediGold, complete and return the form below.

2014 Disenrollment Form

Legal Forms

Allow family members and others to access information MediGold has on file for you.

Release of Information Form

Appoint someone to represent you on formal matters, such as appeals or grievances.

CMS Appointment of Representation Form

Authorize someone to act on your behalf in regard to private, health-related decisions or legal matters.

Power of Attorney

Member Forms

If you're a new member, help us better understand your health and needs. Take your Personal Health Survey online today!

Personal Health Survey

Allow MediGold to release information regarding your MediGold coverage to family members or other representatives.

Release of Information Form

Prescription Drug Forms

Start receiving your prescription drugs through our mail order pharmacy.

CVS Caremark Prescription Mail Order Form

If you paid out-of-pocket for covered prescription medication, complete a claim form to get reimbursed for the covered amount of the medication.

CVS Caremark Drug Claim Form

Request a coverage determination or exception to MediGold’s drug formulary.

Request for Medicare Prescription Drug Coverage Determination

File an appeal related to your Part D prescription drug benefits.

Request for Redetermination of Medicare Prescription Drug Denial

Prior Authorization Forms

Request prior authorization for medical services and procedures requiring it.

Prior Authorization Form - Central

Prior Authorization Form - Southeast

Prior Authorization Form - Southwest

Part B Services Prior Authorization Form - Central

Part B Services Prior Authorization Form - Southeast

Part B Services Prior Authorization Form - Southwest

View a list of services requiring prior authorization.

Prior Authorization List

Last Updated 2/4/2014 2:53:51 PM