Forms

You’ll find the main forms you may need as a Tufts Health One Care member here. 

• Centers for Medicare & Medicaid Services Appointment of Representative Form — Use this form to allow a person to act on your behalf regarding a specific complaint, grievance decision review, internal appeal or external review. 
• Medicare Complaint Form (link opens outside Tufts Health Plan's website) — Use this form to submit your feedback directly to Medicare about your Medicare or prescription drug plan issues. 
• Authorization to Disclose Protected Health Information (PHI) Form — Use this form to let us share your PHI with a person you choose. 
• Board of Hearing (BOH) External Review Request Form — Use this form to file for an expedited external review with the BOH. 
• One Care Enrollment Decision Form and Instructions (link opens outside Tufts Health Plan's website) — This form will ask you to make decisions about your MassHealth and Medicare coverage. 
• Medicare Prescription Drug Coverage Determination Form and Instructions — Use this form to ask for a prescription drug exception or to request a prior authorization for a drug. 
• Medicare Part D Prescription Drug Redetermination (appeal) Form — Use this form to appeal our decision on one of your drugs. 
• OptumRx Prescription Claim Form — Use this form to get reimbursed for covered prescriptions under your plan. 
• Fraud Awareness Information (link opens outside Tufts Health Plan's website) — The Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity has created educational PDFs to help you recognize possible fraud in areas like the health insurance marketplace, home health, medical transportation and more.
• Designated Representative Form — This form may is used to designate a representative to act on a member’s behalf and authorize Tufts Health Plan to disclose the member’s protected health information to the representative.

If you have questions about which form to use or you need assistance completing one of these forms, call us toll-free at 1-855-393-3154 (TTY: 711), seven days a week, from 8 a.m. to 8 p.m. 

H7419_5559B_CMS Approved 
Page modified on: 6/12/2018 2:39:47 PM