Request for Medicare Prescription Drug Coverage Determination

Enrollee Information (Step 1 of 6)

Welcome to the Providence Medicare Advantage Request for Medicare Prescription Drug Coverage Form.

*Enrollee Name *Date of Birth

*Enrollee Member ID

Prescriber Name Prescriber Phone Number

*Who are you?

*Phone Number

Email Address:

Address:

Fax

NOTE: You must provide documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form or a written equivalent). One of these documents is required in order to process this request. If an electronic version is not available, please contact the Pharmacy Team at (503) 574-7400 or 1-877-216-3644 or fax to (503) 574-8646 or 1-800-249-7714.

*Requestor Name:

*Relationship to Enrollee:

*Requestor's Phone Number

Requestor's Email Address: