Additional Information/Forms

2026 Part D Direct Claim Form

2026 Medical Direct Claim Form

2026 ACH Letter & Contract
This contract will allow you to pay The Health Plan bill automatically each month with the Automated Payment Program. Your premium will be deducted on the 5th of each month.

2026 Provider Confirmation for Special Supplemental Benefits for the Chronically Ill

If you are a member of SecureCare D-SNP or SecureChoice Optimum and think you may be eligible for SSBCI benefits, you can give this form to your provider to fill out and return to us. Special Supplemental Benefits for the Chronically Ill (SSBCI) are for qualifying members with conditions such as diabetes mellitus, cardiovascular disorders, chronic heart failure, cancer, and chronic lung disorders. This is not a complete list of conditions. Having a listed condition does not guarantee eligibility. Other requirements apply.

2026 Appointment of Representative Form
This form will allow you to authorize an individual to act as your representative for requesting a coverage determination or an appeal.

2026 Medical Pre-Authorization Form
This form allows you to request for Medical Pre-Authorization.

2026 Medicare Secondary Payer Form
Required form by the Centers for Medicare and Medicaid Services.