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, 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.

2019 Plan Forms

English:
Enrollment Application
Plan Change Form
Payment Option Form
Scope of Appointment

Spanish:
Formulario de Inscripción Individual
Formulario de Cambio de Plan
Formulario de Opción de Pago
Formulario de Confirmación del Alcance de la Cita

Other Forms:
Medical Claim Form
Authorization to Release Protected Health Information
Permission to Verbally Discuss Protected Health Information 
Autorización para analizar verbalmente información de salud protegida

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...?

Get to Know HealthPoint

One of our community health center partners, HealthPoint has many locations across King County. Their approach to health care is to bring together all the services someone needs to be healthy, in one place. We support their model of whole person care and together, our goal is healthier people and a healthier community.

FIND A CLINIC NEAR YOU

☏ HAVE QUESTIONS ?

Sales Team

Get real answers
from real people

Phone: 1-800-944-1247
Email: Sales@chpw.org

x

 

We are now 
Community Health Plan of Washington
Medicare Advantage


With a new name comes new benefits.
Our  2020 Medicare Advantage plan details
will be available on October 1st, 2019.

 

Bookmark this page for updates!