- To access the Senior Preferred enrollment application, please visit the enrollment page.
Prescription (Part D) forms
- To request an initial Part D coverage determination or exception, please use this form:
- To request a Part D redetermination, first-level appeal, please use this form:
- Authorization for Disclosure of Protected Health Information Form
- Member Claim Form
- Payment Change Form
- Appointment of Representative Statement Form (If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal or grievance, please refer to this form).
Completed forms can be mailed or faxed to:
Senior Preferred (HMO)
840 Carolina Street
Sauk City, WI 53583
Fax: (608) 881-8396
This webpage was updated on November 19, 2019.