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 
• 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
• Scope of Sales Appointment Confirmation Form
• Introductory Letter
• Open Enrollment Instructions
• RX Comparison Form
• Coupon Form 
• Continuity of Care Request Form 

The above information is current as of October 2011.

Medicare-Approved HMO plan

H4564_SC_WEB_FORMS_2012  CMS Approved 9/13/2011