Forms

My Advance Care Plan (Form)

My Advance Care Planning Guide

Alternate Address Form

Authorization for Use or Disclosure of Health Plan Information (Designated Representative)

Authorization to Release/Obtain PHI

Formulario de Información Sobre Reclamos de Salud Conductual

Disabled Dependent Certification Form

Formulario de Certificación de Dependiente Discapacitado

Authorization for Use or Disclosure of Substance Use Disorder Services Information

Medicaid Primary Care Provider (PCP) Change Request

Personal Health Information (PHI) Restriction Form

Revocation of Authorization Form

Autorización para Divulgar y Obtener Información Médica Protegida (PHI)

Autorización para el Uso o la Divulgación de Información Sobre los Servicios de Trastornos por Uso de Sustancias

Autorización para la utilización o divulgación de la información del plan de salud (Representante autorizado)

Formulario de solicitud de cambio de proveedor de atención primaria (PCP)

Revocación de la Autorización

Solicitud de Comunicación de la Información Médica Protegida (PHI) por Medios o Ubicación Alternativos

Solicitud de Restricción del Uso y la Divulgación

Auto Debit Form for Individual & Family Plan Members

Instructions on How to File a Claim

Out-of-Network Chiropractic Claim Form

Out-of-Network Vision Claim Form

New Member Reimbursement Form

Coordination of Benefits Information

Medicaid Member Appeals Packet

Medicaid Members Complaint Packet

Commercial Appeals Packet

Commercial Complaint Packet

Self-Funded Appeal Packet

Sentara Community Complete (HMO D-SNP) Appeal Coverage Packet

Sentara Medicare Appeal Coverage Packet

Sentara Community Complete Appeals

Sentara Community Complete (HMO D-SNP) Drug Coverage Determination Form

Sentara Community Complete (HMO D-SNP) Prescription Drug Redetermination Request Form

Medicare Drug Coverage Determination Request Form

Medicare Prescription Drug Redetermination Request Form

Out-of-Area Dependent Child Form — for members enrolled in the Out-of-Area Dependent Program

Out-of-Area Dependent Child Form — for members whose employer has purchased the Out-of-Area dependent rider

Primary Care Provider Change Request Form

Formulario de solicitud de cambio de proveedor de atención primaria (PCP)

Mail Order Frequently Asked Questions

Mirena Eligibility Form

Mirena Order Form

Specialty Pharmacy Frequently Asked Questions (Proprium Pharmacy)

Commercial Member Reimbursement Form

Medicare Member Reimbursement Form

Medicaid Member Reimbursement Form

Sentara Medicare Part D Drug Coverage Determination Form

Medicare Part D Redetermination Request (Appeal) Form

Transitioning Care to Sentara Health Plans