Medicare Plan Documents

Looking for forms related to your Medicare Advantage (MA) Plan? You’ve come to the right place.

Evidence of Coverage (EOC) Documents

• Dual Complete: English | Spanish
• Dual Select:  English | Spanish
• MA Plan 1:  English
• Ma Plan 2: English
• MA Plan 3:  English | Spanish
• MA Plan 4:  English | Spanish
• MA Freedom: English

Medicare Advantage Forms

Enrollment

If you are new to Medicare or switching from another plan, you can enroll using this application:

• Enrollment Application – English | Formulario de inscripción individual – Spanish

You can also enroll online or by phone 1-800-944-1247 (TTY: 711).

Plan Change

Use this form if you are already enrolled and wish to change your plan during the Annual Election Period (AEP) or a Special Election Period (SEP)*:

• Plan Change Form – English
• Formulario de Cambio de Plan – Spanish

*see also: Special Enrollment Period Election Form below

For more information about changing your plan, visit our Eligibility page or contact our Enrollment Specialists at 1-800-944-1247 (TTY: 711).

Special Enrollment Period Election

Use this form if you’ve experienced life-changing circumstances that may qualify you for a Special Enrollment Period:

Special Enrollment Period Election Form – English
Formulario de elección de inscripción especial – Spanish

For more information, see our Eligibility page.

Payment Option

Use this form to choose how you want to pay your plan premium: mail a check, Electronic Funds Transfer (EFT), or automatic deduction from your monthly Social Security benefit check.

• Payment Option Form – English
• Formulario de Opción de Pago – Spanish

Authorization to Disclose Health Care Information

Use this form to allow CHPW Medicare Advantage to disclose your protected health information (PHI) to a person or organization that you choose. For example, if you want your appointed representative, caregiver, power of attorney, skilled nursing facility, group care home, or other health facility to receive information about your health.

Authorization to Disclose Protected Health Information – English
Autorización para la divulgación de información personal sobre salud – Spanish

Appointment of Representative

Complete and mail this form to appoint a representative. An appointed representative is a relative, friend, advocate, doctor, or another person who is authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. Note: both you and your representative must complete the form.

Appointment of Representative – English
Nombramiento de un Representante – Spanish
Appointment of Representative – Large Print

Mail your completed form to:
Community Health Plan of Washington
ATTN: CHPW Medicare Advantage
1111 Third Avenue, Suite 400
Seattle, WA 98101

We’re here to help.

If you have questions or want to request hard copies of plan documents or forms, please contact Customer Service at 1-800-942-0247 (TTY: 711), 8:00 a.m. to 8:00 p.m., 7 days a week.