Medicare forms and documents for Palm Beach.

Bright HealthCare's job is not complete when you enroll in a Medicare Advantage plan. We are available to help throughout your healthcare experience. View some of our additional resources you may need while a Bright HealthCare member.

2021 Forms and Documents

Do you want to give a friend, family member or lawyer the right to make some decisions for you? You can give someone you trust the right to act on your behalf. Just fill out this appoint a representative form and mail to the address below. The appointment lasts up to a year unless you cancel it first.

Bright Health PO Box 853959 Richardson, TX 75085-3959

Appointing a representative

English Español

Disenrolling from Bright Health


Multi-language interpreter services

English


National Coverage Determination (NCD) Information

English Español 中文


Notice of nondiscrimination

English


Medicare reimbursement claim form

English

Español

Comprehensive Formulary

List of Formularies


Coverage determination request form

English


Extra financial help for prescription drugs


Medication Therapy Management program


Prescription drug transition policy


Prior authorization criteria

English


Quality assurance and utilization management


Redetermination of prescription drug denial request form

English


Reimbursement claim form

English Español


Step therapy criteria

English


Safe use of opioid pain medication – information for Medicare Part D patients

English


Mail order summary

English


Mail order form

English Español

Enrollment Form

English

Español


Extra Optional Benefits Enrollment Form

English


Evidence of Coverage

H3281005 English

H3281005 Español

H4709024 English


Annual Notice of Change

English H3281005

Español H3281005



2021 LIS Premium Summary

English


2020 LIS Premium Summary

H3281005 English

H4709024 English

2020 Forms and Documents

Do you want to give a friend, family member or lawyer the right to make some decisions for you? You can give someone you trust the right to act on your behalf. Just fill out this appoint a representative form and mail to the address below. The appointment lasts up to a year unless you cancel it first.

Bright Health PO Box 853959 Richardson, TX 75085-3959

Appointing a representative

English Español

Audiology directory

English

Authorization to share personal information

English

Automatic premium payment authorization form

English

Bright Extra Benefits (optional) enrollment form

English

Dental directory

English PDF

Disenrolling from Bright Health

Enrollment Forms

English Español

Evidence of Coverage

H4709005 English H4709005 Español H4709003 English H4709003 Español H4709001 English H4709001 Español H3281005 English H3281005 Español H3281003 English H3281003 Español H3281001 English H3281001 Español

Medicare reimbursement claim form

English

Multi-language interpreter services

English

National Coverage Determination (NCD) Information

English Español 中文

Notice of nondiscrimination

English

Over the Counter Coverage

English

Pharmacy directory

English Español

Provider directory

English Español

Scope of appointment confirmation

English

Vision directory

English

Comprehensive Formulary

English Español 中文

Monthly formulary changes

English

Coverage determination request form

English

Extra financial help for prescription drugs

Medication Therapy Management program

Prescription drug transition policy

Prior authorization criteria

English

Quality assurance and utilization management

Redetermination of prescription drug denial request form

English

Reimbursement claim form

English Español

Step therapy criteria

English

Safe use of opioid pain medication – information for Medicare Part D patients

English

Mail order summary

English

Mail order form

English Español

Website Last Updated: Mar 8 2021

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