2023 Member Forms

Enrollment Forms:

Medical benefits:

Pharmacy benefits (including Part D vaccines):

Dental Reimbursement form:

Prescription Drug Forms:

Billing Form:

Authorization and Appointment of Representative Forms:

Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in StrideSM (HMO) depends on contract renewal.

Links on this page may take you away from the Harvard Pilgrim Health Care website.

H6750_23036                                                        Last Update: 11/27/2023