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  2. HHO - Delaware
  3. Medicare D-SNP
  4. D-SNP Member Resources
  5. D-SNP Member Forms and Documents

Member Forms and Documents

2025 Highmark Health Options Duals (HMO SNP) Enrollment Forms

Highmark Health Options Duals – 2025 Enrollment Form

Highmark Health Options Duals – Solicitud de inscripción a Medicare D-SNP 2025

Medicare D-SNP Forms and Documents

Appointment of Representative Form (CMS Form-1696)

Disaster or Emergency Information

Medicare Complaint Form

Request for Drug Coverage Form

Request for Medicare Prescription Drug Coverage Determination Instructions

Request for Medicare Prescription Drug Coverage Determination Form

Standard Redetermination Request Form

Highmark Health Options Duals is offered by Highmark Blue Cross Blue Shield. Highmark BCBSD Inc. d/b/a Highmark Blue
Cross Blue Shield offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal.

Medicare Ombudsman Website
Best Available Evidence
H7710_24_4461_M_2025_B


Last updated on March 25, 2025.