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Member forms

On this page you’ll find important forms you can use to request coverage exceptions, request prior authorization, and more.

Administrative Forms

Prior Authorization Form MI

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Authorization to Release PHI MI

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Appeals and Grievances

Coverage Determination Form (OptumRx) MI

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Redetermination Request Form MI

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File a Complaint MI

Appointment of Representative Form

Appointment of Representative Form

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English PDF Last Updated 8/4/2022
Spanish PDF Last Updated 8/4/2022

Other Important Forms

Chronic Condition Form

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