All of your plan-related forms are located here. Select the form you need, print and complete it, and mail it back to us.
Plan forms include:
Enrollment Application – If you are new to Medicare, you can enroll using this application form.
Plan Change Form – If you are already enrolled and wish to change your plan during AEP.
Payment Option Form – Choose how you want to pay your plan premium: pay with a check by mail, Electronic Funds Transfer (EFT), or automatic deduction from your monthly Social Security benefit check.
Scope of Appointment – Before you meet in person with a Medicare expert, you must agree to the terms of the appointment. Any meeting with our experts is purely informational and does not obligate you to enroll in any plan.
Authorization to Release Health Care Information – Allows CHPW Medicare Advantage to release your protected health information 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 facilities to receive information about your health.
Permission to Verbally Discuss Protected Health Information – Allows CHPW Medicare Advantage to verbally discuss certain information regarding your health status with people you choose. Any information shared is used to coordinate your health care.
Medical Claim Form – Your insurance claim form.
Appointing 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. If you would like to appoint a representative, both you and your representative must complete the form below and mail it to Community Health Plan of Washington.
Completed forms can be mailed to:
Community Health Plan of Washington
ATTN: CHPW Medicare Advantage
1111 Third Avenue, Suite 400
Seattle, WA 98101