Commonly Used Forms & Resources
Below are commonly used forms and resources for your convenience.
- Gym Reimbursement Form (Service to Senior HMO plan members)- Please read the instructions and complete this online form. (Haga clic aquí para español)
- Advanced Health Care Directive Form: English or Spanish
- Appointment of Representative (by clicking this link, you will be redirected away from Inter Valley Health Plan's website.)
- Authorization to Receive or Release Medical Information
- Medicare Advantage Plan Member Appeals & Grievance
- Request for Medicare Prescription Drug Coverage Determination
- Request for Redetermination of Medicare Prescription Drug Denial
- Manifest MEDEX
- Medicare Complaint Form (by clicking this link, you will be redirected away from Inter Valley Health Plan's website.)
- Ombudsman (by clicking this link, you will be redirected away from Inter Valley Health Plan's website.)