eternalHealth Member Forms and Documents

eternalHealth believes in empowering our members through accessibility and education. Listed on this page are health-related documents that you may need.

If you cannot find what you are looking for, please feel free to give us a call at 1-800-680-4568 (TTY 711).

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Documents for 2023
eternalHealth Massachusetts Plans

Personal Forms

Authorization for Disclosure of Protected Health Information

Complete and return this form when you would like us to share your health information.

Authorization for Disclosure of Protected Health Information

Appointment of Representative Form

Complete and return this form when you would like to appoint a representative to act on your behalf during the appeal process.

Appointment of Representative Form

Advance Directives Information

Complete this legal document that explains how you want medical decisions made about you if you are unable to make the decisions yourself.

Advance Directive Information

Prior Authorizations, Appeals, and Grievances Information

Learn more on how to file a prior auth, appeal, or grievance.

Prior Authorizations, Appeals, and Grievances Information

Plan Forms

Enrollment Form

Complete a paper enrollment form and submit your application for an eternalHealth Medicare Advantage Plan

2023 Enrollment Form

Disenrollment Form

Medicare members are allowed to disenroll from their plan during specific periods throughout the year as specified by CMS (Centers for Medicare and Medicaid). Learn more about disenrollment here.

Disenrollment Form

ACH Form

Pay your monthly eternalHealth Medicare Advantage premiums quickly and easily

ACH Form

Direct Member Reimbursement Form

Complete and return this form to get paid back for medical services or medications that you paid for
yourself.

Direct Member Reimbursement Form

Dental Reimbursement Form

Complete and return this form to get paid back for dental services that you paid for yourself.

Dental Reimbursement Form

Referral Form

Need to see a specialist? Have your Primary Care Provider (PCP) submit the referral form.

Referral Form

Referral Form for American Specialty Health

Need to see a specialist for rehabilitation services, physical therapy, occupational therapy, speech therapy, acupuncture, or chiropractic services? Have your Primary Care Provider (PCP) submit the referral form.

Referral Form for American Specialty Health

Request for Redetermination of Medical Services and Products

If you were denied medical services or products and would like a redetermination, please complete this form.

Request for Redetermination of Medical Services and Products

Member Complaint Form

We take your concerns seriously – please complete the attached form for any complaints.

Member Complaint Form
Summary of Benefits (SoB)

See below for the Summary of Benefits for each of eternalHealth’s four 2023 Medicare Advantage Plans.

Click your plan’s name below to access its related Summary of Benefits (SOB) for 2023:

Evidence of Coverage (EoC)

See below for the Evidence of Coverage for each of eternalHealth’s four 2023 Medicare Advantage Plans.

Your Evidence of Coverage will provide you with detailed information on anything you may need to know, including what your plan covers, what your payments will look like, how you can communicate with eternalHealth and other local Medicare resources, and your rights and responsibilities as a member.

Click your plan’s name below to access its related Evidence of Coverage (EOC) for 2023:

Annual Notice of Change (ANoC)

See how your plan will change in the coming year.

Click your plan’s name below to access its related Annual Notice of Change (ANoC) for 2023:

Formulary

A formulary is a list of generic and brand name prescription drugs that are covered under your health plan.

Click here to access the 2023 formulary for the following plans:

  • eternalHealth Forever HMO
  • eternalHealth ForeverMore HMO
  • eternalHealth Freedom PPO

Click here to access the 2023 formulary for the following plan:

  • eternalHealth Give Back PPO

You can find detailed information about eternalHealth’s prescription drug benefits here.

Over-the-Counter (OTC) Catalog

As a member of eternalHealth you have a quarterly Over-the-Counter allowance. View the catalog for information on how to use your benefits as well as the products that are covered.

View OTC Catalog

Part D - Prescription Drug Forms

Request for Medicare Prescription Drug Coverage Determination

This form will allow you to determine your coverage of a prescription drug.

Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination Of Medicare Prescription Drug Denial

You may appeal a coverage determination about a prescription drug with this form.

Request For Redetermination Of Medicare Prescription Drug Denial

Low Income Subsidy for Medicare Prescription Drug Coverage

For more information on receiving extra help from Medicare for your prescription drug coverage, please see the chart here. If you have any questions don’t hestitate to contact eternalHealth.

2023 Low Income Subsidy for Medicare Prescription Drug Coverage

Seeing Some Unfamiliar Words?

We want to give you all the information you need to make the best choices for you and your family.

forms doc image 3

We get it, Medicare is confusing,
so we’ve put together a list of
common words.

Vocabulary List
Page Last Updated On: May 9, 2023
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Tom Cunniffe

Tom Cunniffe

Director of Operations 

Tom Cunniffe comes to eternalHealth with over 20 years of healthcare operations’ experience, having held leadership positions in Call Center, Enrollment, Credentialing, UAT and Reimbursement teams. Tom has worked with Medicaid, Commercial and Medicare lines of business and has consistently built teams who are metrics driven with proven successful outcomes. Making sure our business strives for an efficient, best-in-class customer experience is at the center of Tom’s philosophy.

Tom has a bachelor’s degree from Fordham University and a master’s in business administration from University of Massachusetts at Amherst.

Tom Lawless

Tom Lawless

Chief Financial Officer

Tom Lawless has spent the past 20+ years building, sustaining, and growing new healthcare-related programs that balance fiscal responsibility & prudence with creativity & innovation, focusing on models of care that are novel, person-centered, and improve the social welfare of those who are served. He is very excited to continue doing so in his role as the Chief Financial Officer of eternalHealth.

Tom comes to eternalHealth from a not-for-profit, member-centric, health insurance cooperative. He helped the company continuously strive toward its dual goals of thriving financially, while keeping members at the very epicenter of its mission and service model. While there, Tom also spearheaded the creation of a brand new private, charitable foundation, which will be meaningfully giving back to those in need in the surrounding communities for years to come. Previously, Tom worked in the finance department of a successful hospice that provided high-quality care to persons experiencing their unique and poignant end-of-life journeys, assuring that the appropriate financing was always available. Tom’s career began as a civil servant in the Wisconsin Medicaid program, where he helped to create a program that expanded the institutional entitlement to care into home and community-based settings. Starting with only a blueprint in hand, the program now serves more than 57,000 frail elders and disabled adults and is considered a national model. Growing into a senior leadership role, Tom was a key architect of an innovative financing model, through which the public and private sectors successfully collaborated to better the lives of persons in great need.

Tom holds undergraduate and graduate degrees from the University of Chicago, with additional graduate work in economics completed at the University Wisconsin-Madison.

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