Find A Form

Elderplan makes it easy to find the information you need. Please use the links below to access helpful forms.

2014 Plan Forms

To request a Part D Coverage Determination for Elderplan Members Only via secure Web form click here.

To request Part D Coverage Re-determination for Elderplan Members Only via secure Web form click here.

To activate your OTC debit card, to check your card balance or for a complete list of participating retailers, please visit www.otcmember.com.

Authorization For Release of Health Information to HIPAA

The following forms are also available on the Centers for Medicare and Medicaid Services (CMS) website:

Appointment of Representative:
http://www.cms.gov/cmsforms/downloads/cms1696.pdf

Coverage Determination:
http://www.cms.gov/MedPrescriptDrugApplGriev/Downloads/ModelCoverageDeterminationRequestForm.pdf