Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form (PDF)

• Transition of Care Form (PDF)

Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form (PDF)

Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

• Appointing a Representative (PDF)

We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.

• Disenrollment Form (PDF)

Need help at the doctor's office?

Visiting the doctor’s office can be difficult when you are trying to remember the details of your medical needs and health concerns over a period of time. With the amount of paperwork to fill out and questions to answer, it can be hard to make sure you are able to tell your doctor exactly what the problems are.   

Don’t wait until you get to the doctor’s office to start thinking of the reasons for your appointment. Try these helpful doctor visit guides from Magnolia Health to learn what to expect and prepare to ask your own questions about your medications, treatment options, warning signs, health tips and diet needs.

These helpful guides include details about common medical issues, so you’ll be ready to talk to your doctor about your issue, find out the information you need, and better understand what to expect from your visit.

1. Click on any of the forms listed below
2. Print out the form you need
3. Fill in the answers before your appointment
4. Take it with you to the doctor

These helpful doctor visit guides can be useful when you're being seen for any of the following conditions:

• Asthma (PDF)
  
• Coronary Artery Disease (PDF)
  
• Diabetes (PDF)
  
• High Blood Pressure (PDF)
  
• High Cholesterol (PDF)
  
• Weight Management (PDF)
• Adult Wellness Visit Checklist (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)

Use this form when you want to allow us to share your health information with a person or group:

• PHI Authorization Form - English (PDF)

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

• PHI Revocation Form - English (PDF)
• PHI Revocation Form - Spanish (PDF)

Need help at the doctor's office?

Visiting the doctor’s office can be difficult when you are trying to remember the details of your medical needs and health concerns over a period of time. With the amount of paperwork to fill out and questions to answer, it can be hard to make sure you are able to tell your doctor exactly what the problems are.   

Don’t wait until you get to the doctor’s office to start thinking of the reasons for your appointment. Try these helpful doctor visit guides from Magnolia Health to learn what to expect and prepare to ask your own questions about your medications, treatment options, warning signs, health tips and diet needs.

These helpful guides include details about common medical issues, so you’ll be ready to talk to your doctor about your issue, find out the information you need, and better understand what to expect from your visit.

1. Click on any of the forms listed below
2. Print out the form you need
3. Fill in the answers before your appointment
4. Take it with you to the doctor

These helpful doctor visit guides can be useful when you're being seen for any of the following conditions:

• Asthma (PDF)
  
• Coronary Artery Disease (PDF)
  
• Diabetes (PDF)
  
• High Blood Pressure (PDF)
  
• High Cholesterol (PDF)
  
• Weight Management (PDF)

• Member Reimbursement Claim Form - English (PDF)
• Member Reimbursement Claim Form - Spanish (PDF)

• Inpatient Medicare Authorization Form (PDF)
• Outpatient Medicare Authorization Form (PDF)

• PCP Change Request Form - English (PDF)
• PCP Change Request Form - Spanish (PDF)

• Late Enrollment Penalty (LEP) Reconsideration (PDF)