Member forms and documents

Access your member forms and documents quickly when you need them. 

Highmark Health Options Duals (HMO SNP) Enrollment Forms 

Use these forms when you’re ready to become a D-SNP member.

Medicare D-SNP forms and documents

SSBCI Provider Attestation Form (Link to SSBCI BSBC Form)

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