MEMBER FORMS

Enrollment

To access the Senior Preferred enrollment application, please visit the enrollment page. ​​​

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Prescription (Part D) forms

• To request an initial Part D coverage determination or exception, please use this form:
  • Request for Medicare Prescription Drug Coverage Determination Form
• To request a Part D redetermination, first-level appeal, please use this form:
  • Request for Medicare Prescription Drug Coverage Redetermination Form
    

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Other forms

• Member Claim Form
• Payment Change Form
• Authorization for Disclosure of Protected Health Information 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
840 Carolina Street
Sauk City, Wisconsin 53583

This web page was updated on October 1, 2018.