Medicare forms and documents for New York City.

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

Comprehensive Formulary

List of Formularies

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

Disenrolling from Bright Health


Multi-language interpreter services

English


National Coverage Determination (NCD) Information

English Español 中文


Notice of nondiscrimination

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

Comprehensive Formulary

English Español 中文

Comprehensive formulary (HMO SNP)

English Español 中文

Monthly formulary changes

English

Monthly formulary changes (HMO SNP)

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

Annual Notice of Changes H2288001 English H2288001 Español H2288001 中文 H2288002 English H2288002 Español H2288002 中文 H2288005 English H2288005 Español H2288005 中文 H9516001 English H9516001 Español H9516001 中文 H9516002 English H9516002 Español H9516002 中文

Audiology directory

English Español 中文

Audiology directory (HMO SNP)

English Español 中文

Authorization to share personal information

English

Automatic premium payment authorization form

English

Bright Extra Benefits (optional) enrollment form

English

Dental directory (HMO)

English PDF

Dental directory (HMO SNP)

2020 English PDF 2019 English PDF 2019 Español PDF 2019 中文 PDF

Disenrolling from Bright Health

Enrollment Forms English Spanish English DSNP Spanish DSNP

Evidence of Coverage

H2288008 English H2288008 Español H2288005 English H2288005 Español H2288003 English H2288003 Español H2288002 English H2288002 Español H2288001 English H2288001 Español H9516002 English H9516002 Español H9516001 English H9516001 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 (HMO)

English Español 中文

Pharmacy directory (HMO SNP)

English Español 中文

Provider directory (HMO)

English Español 中文

Provider directory (HMO SNP)

English Español 中文

Scope of appointment confirmation

English

Vision directory (HMO)

English Español 中文

Vision directory (HMO SNP)

English Español 中文

Website Last Updated: Mar 8 2021

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