Request for Redetermination of Medicare Prescription Drug Denial

Enrollee Information (Step 1 of 5)

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Welcome to the Providence Request for Redetermination of Medicare Prescription Drug Denial Form.

Enrollee Information

*Enrollee Name:

*Date of Birth
(MM/DD/YYYY):

*Enrollee Member ID:

Prescriber's Information

Prescriber Name:

Prescriber Phone Number
(###)###-####
or ###-###-####:

User Information

*Who are you?

*Phone Number
(###)###-####
or ###-###-####:

Email Address:

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
(###)###-####
or ###-###-####:

Requestor's Email Address:

*Requestor's Address:

*Requestor's City:

*Requestor's State:

*Requestor's Zipcode:

Providence Medicare Advantage Plans is an HMO, HMO-POS and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

H9047_PHAAM20

Webpage is current as of 1/1/2021