Medicare forms and documents for Orlando-Tampa.

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.

2022 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

Automatic Premium Payment Authorization Form English Español 中文


Disenrolling from Bright Health


Extra Help (LIS) summary


Multi-language interpreter services

English


National Coverage Determination (NCD) Information

English Español 中文


Notice of nondiscrimination

English Español 中文


Medicare reimbursement claim form

English

Español


Authorization to Share Personal Health Information (ASPI)

English Spanish Chinese

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


Authorization to Share Personal Health Information (ASPI)

English Spanish Chinese

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


Annual Notice of Changes

H3281003 English

H3281003 Español

H4709003 English

H4709003 Español


Evidence of Coverage

H3281003 English

H3281010 English

H4709003 English


2021 LIS Premium Summary

English


2020 LIS Premium Summary

English Español

Enrollment Form

English

Español


Extra Optional Benefits Enrollment Form

English


Annual Notice of Changes

H3281001 English

H4709001 English

H4709001 Español


Evidence of Coverage

H3281001 English

H3281009 English

H4709001 English


2021 LIS Premium Summary

English


2020 LIS Premium Summary

English Español

Website Last Updated: Apr 25, 2022

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