MediGold
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Forms

Billing & Payment Forms

Pay your MediGold monthly premium automatically each month through Electronic Funds Transfer (EFT). The link below is a printable version of our EFT form.

2015 Electronic Funds Transfer Form

MediGold members are have the option to complete the Electronic Funds Transfer (EFT) form online. To complete your EFT form online, please click here.

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, please complete and return the form below.

2015 Disenrollment Form

If you are currently a MediGold member, and you would like to disenroll from our supplemental dental plan, please complete and return the dental plan disenrollment form below.

2015 Dental Plan 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 (by clicking the link below, you will be leaving the MediGold website).

CMS Appointment of Representative Form

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

Power of Attorney

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 (by clicking the link below, you will be leaving the MediGold website).

Request for Medicare Prescription Drug Coverage Determination

File an appeal related to your Part D prescription drug benefits (by clicking the link below, you will be leaving the MediGold website).

Request for Redetermination of Medicare Prescription Drug Denial

Prior Authorization Forms

Request prior authorization for medical services and procedures requiring it.

Prior Authorization Form

View a list of services requiring prior authorization.

Prior Authorization List

Last Updated 10/21/2014 12:11:46 PM