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Plan Resources

Plan Resources

Information Last Updated:11/12/2021

Quarterly Newsletters

Winter Newsletters (English | Spanish | Chinese | Korean | Vietnamese)

Spring Newsletters (English | Spanish | Chinese | Korean | Vietnamese)

Summer Newsletters (English | Spanish | Chinese | Korean | Vietnamese)

Fall Newsletter (English | Spanish | Chinese | Korean | Vietnamese)

Forms

2021 Over-the-Counter (OTC) Order Form
(English | Spanish | Chinese | Korean | Vietnamese)

2022 Over-the-Counter (OTC) Order Form
(English | Spanish | Chinese | Korean | Vietnamese)

2021 Appeal Form
(English | Spanish | Chinese | Korean | Vietnamese)

Appointment of Representative Form (English | Spanish)

Authorization for Disclosure of Protected Health Information

Enrollment Forms (2021)

Enrollment Forms (2022)

2021 Grievance Form
(English | Spanish | Chinese | Korean | Vietnamese)

Authorization Service Request Form (English | Spanish)

Benefit Highlights

2021 Health Risk Assessment (HRA)
(English | Spanish | Chinese | Korean | Vietnamese)

2022 Health Risk Assessment (HRA)
(English | Spanish | Chinese | Korean | Vietnamese)

To complete an Electronic HRA click here

DeltaCare USA Dental
Medicare Fee Schedule | Fee Schedule for Dual Eligibles

Western Dental
Medicare Fee Schedule | Fee Schedule for Dual Eligibles

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