URGENT NOTICE TO PATIENTS WHO HAVE USED OR ARE IN POSSESSION OF EZRI CARE ARTIFICIAL TEARS LUBRICANT EYE DROPS. DISCONTINUE ALL USE. LEARN MORE


INFLATION REDUCTION ACT ALERT – NEW COST-SHARING PROTECTIONS FOR INSULIN FURNISHED UNDER THE PART B BENEFIT THROUGH A QUALIFIED ITEM OF DURABLE MEDICAL EQUIPMENT AND CERTAIN PART B DRUGS. LEARN MORE

Forms

Prescription Drug Coverage Request Form (Online Request)

Request for Redetermination of Medicare Prescription Drug Denial (Online Request)

Appointment of Representative

Authorization for Use and Disclosure of Health Information

Designation of Health Care Surrogate

Disenrollment Form

Hospice – Part D

Living Will

Medical Service Reimbursement Form – Part C

Over the Counter (OTC) Order Form

Prescription Drug Reimbursement Form – Part D

Prior Authorization Form – Part C

Prescription Drug Coverage Request Form

Redetermination of Medicare Prescription Drug Denial

Request for Reconsideration – Part C Appeals