2020 Member Forms
- 2020 Harvard Pilgrim Stride Enrollment Form
- Pre-Enrollment Checklist (pdf)
- OptumRx Home Delivery Prescription Drug Order Form (PDF)
- Prescription Drug Reimbursement Forms:
- Part D (Pharmacy) Coverage Determination Request Form
- Part D Redetermination Request Form
- Electronic Funds Transfer (EFT) Form (pdf)
- Member Reimbursement Form (pdf) - effective 1/1/2020
- Designation of Representative Form (pdf)
- CMS Appointment of Representative form (pdf)
- Authorization to Release Information Form
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.
|Y0098_20060||Last updated: 1/3/2020|