2024 Medicare Stride member forms

Pharmacy benefits (including Part D vaccines):

• OptumRx Reimbursement Form (pdf)

Prescription drug forms:

• Part D Redetermination Request Form (pdf)
• Medicare Part D Reconsideration Form (pdf)
• Optum Claim Form Medicare Part D (pdf)

Authorization and appointment of representative forms:

• Designation of Representative Form (pdf)
  This form will allow a designated representative to receive all information pertaining to your health information and make decisions or changes related to your benefit plan.
• Centers for Medicare & Medicaid Services (CMS) Appointment of Representative form (pdf)
  This form will allow someone to file an appeal or grievance on your behalf.
• Personal Representative Cover Form (pdf)
  Members may attach their legal personal representative documents with this cover page.
• Authorization to Release Information Form (pdf)
  This form will allow an authorized representative to speak to us about your protected health information.