Forms

My Advance Care Plan (Form)

My Advance Care Planning Guide

Alternate Address Form

Authorization for Use or Disclosure of Medical Information (Designated Representative)

Authorization to Release/Obtain PHI

Behavioral Health Claim Instructions

Formulario de Información Sobre Reclamos de Salud Conductual

Disabled Dependent Certification Form

Formulario de Certificación de Dependiente Discapacitado

P207A Authorization for Use or Disclosure Of Substance Abuse Records

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 el uso o la divulgación de información médica (representante designado)

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

Coordination of Benefits Information

Medicaid Member Appeals Packet

Medicaid Members Complaint Packet

Commercial Appeals Packet

Commercial Complaint Packet

Self-Funded Appeal Packet

File an appeal for medical items or services for Sentara Community Complete (HMO D-SNP)

File an appeal about a coverage decision for Part C medical services or items

Sentara Community Complete Appeals

Sentara Community Complete Request for Drug Coverage Determination

Request a Redetermination (appeal) for a Sentara Community Complete (HMO D-SNP) Prescription Drug

Sentara Health Plans Medicare Rx (PDP) Coverage Determination Request

Sentara Health Plans Medicare Rx (PDP) Coverage Redetermination Request

Request a standard decision for Medicare Part D (prescription drugs)

Request for Medicare Prescription Drug Coverage Redetermination

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 FAQs (Proprium Pharmacy)

Commercial and Medicaid Member Reimbursement Form

Medicare Member Reimbursement Form

Medicaid Member Reimbursement Form

Medicare Member Reimbursement Form (Spanish)

Sentara Medicare Plans Request for Drug Coverage Determination

Part D Redetermination Request (Appeal) Form

Transitioning Care to Sentara Health Plans