2013 Member Forms for Medicare: Life Improvement Plan (HMO SNP)
We want to make signing up for the Medicare Life Improvement Plan as easy as possible. Below, you will find all the forms and documents you need to make sure you get good health coverage.
Need help? Just call us or visit a Healthfirst community office near you. We can help you fill out any of these forms.
To open the forms, you will need Adobe Acrobat software installed on your computer. Download the software by clicking here. * Please note that clicking on this link will take you away from the Healthfirst website.
Benefits Documents |
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Life Improvement Plan (HMO SNP) |
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| Summary of Benefits |
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| Evidence of Coverage |
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Prescription Drugs Covered By Your Plan (Formulary)
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General Forms and Documents |
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| Enrollment Form |
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| Short Enrollment Form |
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| Multi-language Interpreter Services | Multi-language |
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Prescription Claim Form Fill out this form if you need money back for buying a prescription medicine that is usually covered by your Healthfirst plan |
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Appointment of Representative Form |
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| Health Care Proxy Information |
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Health Care Proxy Form How to make a living will and/or choose who will make health care |
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Part D Coverage Determination Form Fill out this form if you need:
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CMS Website - English * Please note that clicking on this link will take you away from the Healthfirst website. |
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Member Reimbursement Form |
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| Part D Redetermination Request Form | English Español |
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| OTC Reimbursement Form |
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Federal Privacy Notice |
English |
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New York State Privacy Notice |
English |
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* = By clicking this link, you will be sent to another website.
Healthfirst Medicare Plan is a Coordinated Care plan with a Medicare contract and a contract with the New York Medicaid program.
H3359_MKT13_17 CMS Approved 11152012
