Scott & White Health Plan

Forms

You may download any of the following forms.

• Application Packet  
  • Enrollment Form and Instructions 
  • Coordination of Coverage Form for Part D 
  • Automatic Payment Sign-up Form 
• Change Form 
• Coverage Determination Request Form 
• Medicare Part D Coverage Determination Request Form 
• Medicare Part D Redetermination Requests 
• Request for Reconsideration of Medicare Prescription Drug Denial Form 
• Appointment of Representative Form

The above information is current as of October 2010.

"Medicare-Approved HMO"

H4564_SC_WEB_FORMS_2011_REV_122010  CMS Approved 02/08/2011