Forms

Documents on this page are available in Portable Document Format (PDF). Adobe Reader (free) may be used to open these files.

• Information on Advance Directives (pdf 119.32 kB) , including the Living Will and Health Care Surrogate
• Assign someone to represent you in accordance with HIPAA regulations with an Appointment of Representative (pdf 222.04 kB) Form
• Authorization to Disclose Protected Health Information (pdf 90.06 kB)
• Specify who can communicate with your health care team using the Communication Directive (pdf 30.16 kB) Form
• These forms can be used to request an exception to your drug coverage:
  • Request for Medicare Prescription Drug Coverage Determination (pdf 556.17 kB) is for member use.
  • Medicare Part D Coverage Determination Request (pdf 259.65 kB) is for healthcare provider use.
• 2010 Direct Pay Capital Health Plan Medicare Advantage (HMO) Enrollment Application (pdf 351.40 kB)
• 2010 Capital Health Plan Retiree Advantage (HMO) Enrollment Applications are available by contacting your employer or Capital Health Plan Member Services