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Forms for AlohaCare Members


Find forms that you may need to fill out and return to AlohaCare.

Alohacare QUEST


  1. Appointment of Representative: This form gives permission for a person to act on your behalf to file a grievance, appeal or coverage determination for you. 
  2. Protected Health Information Authorization Form: Give AlohaCare permission to release your private health information to another person that you designate. (Updated 010/2013)
  3. Member Grievance Form: Let us know if you are unhappy with the services you receive from AlohaCare or your doctor.  
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AlohaCare Advantage (HMO)


Below is a list of Medicare forms. Each form includes directions on how to submit it to AlohaCare or other organizations. You can also mail forms to AlohaCare: 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI 96814. You can fax forms to 973-0726 or toll-free at 1-800-830-7222.

 
  1. Appointment of Representative: This form gives permission for a person to act on your behalf to file a grievance, appeal or coverage determination for you. You may give any person permission to act on your behalf for these purposes by filling out this form. Both you and the person that is to act on your behalf must sign the form before sending it to us.
     
  2. Request for Medicare Prescription Drug Coverage Determination: If your drugs are not covered by AlohaCare Advantage, you can fill out this form to request an exception. By requesting an exception, you are asking us to cover your drug even though it is not on our Formulary. 
     
  3. Request for Redetermination of Medicare Prescription Drug Denial: Did AlohaCare Advantage deny your request to cover a drug that is not on our formulary? Fill out this form if you do not agree with our decision and want us to look at it again. Be sure to include additional information on why you feel your drug should be covered. 
     
  4. Request for Reconsideration (Appeal) of Medicare Prescription Drug Denial: Request an independent review of AlohaCare Advantage's re-determination decision on your drug coverage. 
     
  5. Coordination of Benefits/Direct Claim: Submit this form with your receipts to help pay for out-of-pocket drug costs.
     
  6. Medicare Part D Coverage Determination Request: If your drugs are not covered by AlohaCare Advantage, your doctor can also request an exception by filling out this form. By requesting an exception, your doctor is asking us to cover your drug even though it is not on our Formulary.
     
  7. Protected Health Information Authorization Form: Give AlohaCare Advantage permission to release your private health information to another person that you designate. (Updated 010/2013)

     
  8. World-Wide Benefit Reimbursement Form: Fill out this form to file  a claim for reimbursement for emergency services outside the United States.

H5969_400614_1 CMS Approved 02122014

AlohaCare Advantage Plus (HMO SNP)


Below is a list of Medicare forms. Each form includes directions on how to submit it to AlohaCare or other organizations. You can also mail forms to AlohaCare: 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI 96814. You can fax forms to 973-0726 or toll-free at 1-800-830-7222.

 
  1. Appointment of Representative: This form gives permission for a person to act on your behalf to file a grievance, appeal or coverage determination for you. You may give any person permission to act on your behalf for these purposes by filling out this form. Both you and the person that is to act on your behalf must sign the form before sending it to us.
     
  2. Request for Medicare Prescription Drug Coverage Determination: If your drugs are not covered by AlohaCare Advantage Plus, you can fill out this form to request an exception. By requesting an exception, you are asking us to cover your drug even though it is not on the Formulary. 
     
  3. Request for Redetermination of Medicare Prescription Drug Denial: Did AlohaCare Advantage Plus deny your request to cover a drug that is not on our formulary? Fill out this form if you do not agree with our decision and want us to look at it again. Be sure to include additional information on why you feel your drug should be covered.
     
  4. Request for Reconsideration (Appeal) of Medicare Prescription Drug Denial: Request an independent review of AlohaCare Advantage Plus' re-determination decision on your drug coverage. 
     
  5. Coordination of Benefits/Direct Claim: Submit this form with your receipts to help pay for out-of-pocket drug costs.
     
  6. Medicare Part D Coverage Determination Request: If your drugs are not covered by AlohaCare Advantage Plus, your doctor can also request an exception by filling out this form. By requesting an exception, your doctor is asking us to cover your drug even though it is not on our Formulary.
     
  7. Protected Health Information Authorization Form: Give AlohaCare Advantage Plus permission to release your private health information to another person that you designate. (Updated 010/2013) 
     
  8. World-Wide Benefit Reimbursement Form: Fill out this form to file  a claim for reimbursement for emergency services outside the United States.

H5969_400614_1 CMS Approved 02122014