Forms

Member Forms

General Authorization for Release of Confidential Information

• This form is required by Piedmont if a member would like his or her personal health care information shared with another party.

Prescription Reimbursement Standard Claim Form

• In the event that a member overpays for a prescription, he or she will need to complete the Prescription Reimbursement Standard Claim Form.

Prescription Drug Mail Order Form

• The Prescription Drug Mail Order form is available only for certain kinds of drugs. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition.

  Appointment of Representative Form

• If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.

Request for Medicare Prescription Drug Coverage Determination Form

• It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for drugs that are covered by our plan. A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a prescription drug coverage determination or exception request. For a secure electronic Request for Medicare Prescription Drug Coverage Determination form, CLICK HERE.

Request for Redetermination of Medicare Prescription Drug Denial

• In the event that Piedmont has denied the member’s request for coverage and or payment for a prescription drug, the member has the right to ask for a redetermination (appeal) of our decision. For a secure electronic Request for Redermination of Medicare Prescription Drug Denial, CLICK HERE.

Medicare Complaint Form

• If the member would like to provide feedback to Medicare in regards to Piedmont Medicare Advantage the member may do so with this form.

Attestation of Eligibility

• Typically, you may enroll in a Medicare Advantage plan only during the Annual Enrollment Period (AEP). There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of the AEP. The Attestation of Eligibility lists other qualifying Special Enrollment Periods.

Provider Forms

Medical Paper Claim Form

• When a member receives service, the provider provides Piedmont with the following form so that we may process the member’s benefits.

Coverage Determination Request Form for Physicians (Medicare Part D Coverage Determination Request Form)

• This form was developed by AHIP, the AMA, and other entities to provide prescribers with a form to be used to request a coverage determination or exception, support a tiering or formulary exception request, or request prior authorization. It may be completed by an enrollee's prescriber and mailed or faxed to the enrollee’s plan sponsor.

Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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Updated 01/28/2018