Member Forms
The following is a list of forms for use by Community HealthFirst members. If you do not see the form that you need or have questions about any of these forms, please contact Customer Service, 8:00 a.m. to 8:00 p.m., 7 days a week, at 1-800-942-0247 (TTY Relay: Dial 7-1-1). Click on the form title below:
- Enrollment Application 2012
- Change of Plan Form
- Payment Option Form
- Authorization to Release Health Care Information
- Medical Claim Form
- Prescription Drug Claim Form
- Medicare Part D Coverage Determination Request
- Appointment of Representation
Low Income Subsidy Program
To obtain the proper forms to apply for the Low Income Subsidy Program please contact the following:
- Social Security: Monday-Friday, 7:00 a.m. to 7:00 a.m. at 1-800-772-1213 (TTY/TDD hearing impaired at 1-800-325-0778) or www.socialsecurity.gov/prescriptionhelp/
- Medicare: 24 hours a day, 7 days a week at 1-800-633-4227 (TTY/TDD hearing impaired at 1-877-486-2048) or www.medicare.gov