Medicare Plan Documents - Community Health Plan of Washington - Medicare Advantage

Medicare Plan Documents

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 or switching from another plan, you can enroll using this application form. Also see our Enrollment page for other options including an online enrollment application.

Plan Change Form – Use if you are already enrolled and wish to change your plan. Note you can do this only during AEP or if you have a special election period. Contact our Enrollment specialists at 1-800-944-1247 (TTY: Dial 711) for more information.

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.

Authorization to Disclose Health Care Information – Allows CHPW Medicare Advantage to disclose 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.

Medical Claim Form – Your insurance claim form to use if necessary.

2021 Plan Forms

English:
Enrollment Application
Plan Change Form
Payment Option Form

Spanish:
Formulario de Inscripción Individual
Formulario de Cambio de Plan
Formulario de Opción de Pago

2020 Plan Forms

English:
Enrollment Application
Plan Change Form
Payment Option Form

Spanish:
Formulario de Inscripción Individual
Formulario de Cambio de Plan
Formulario de Opción de Pago

Other Forms:
Medical Claim Form
Special Enrollment Period (SEP) Election Form
Formulario de elección de inscripción especial (SEP)

SEP Election Form (Spanish)

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.

Appointment of Representative
Nombramiento de un Representante (Español)
Appointment of Representative (Large Print)

Completed forms can be mailed to:

Community Health Plan of Washington
ATTN: CHPW Medicare Advantage
1111 Third Avenue, Suite 400
Seattle, WA 98101

DID YOU KNOW...?

Stay on Top of Your Prescriptions

Woman grabbing a prescriptionDid you know that certain prescription medicines are available as a 90-day supply? Medicine that you take on a long-term basis to manage your health is called a “maintenance drug.” A 90-day supply makes it easier to keep taking the medicine you need to feel your best. You may also be eligible to receive your long-term medications through free home delivery.

LEARN MORE

☏ HAVE QUESTIONS ?

Sales Team

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Phone: 1-800-944-1247
Email: [email protected]

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