Member Forms and Documents
Here you will find plan-specific and health-related documents that you may need.
If you cannot find what you are looking for, please feel free to give the member services team a call at 1-800-680-4568 (TTY 711).
Choose Your Location
eternalHealth offers Medicare Advantage plans in Arizona and Massachusetts. To review eternalHealth’s Summary of Benefits, Evidence of Coverage, and other important plan information, choose your state below to find documents on your specific plan.
eternalHealth Massachusetts Plan Documents
Personal Forms
We have forms to make every part of your Medicare journey quick and easy. From enrollment forms, the appointment of representative forms, ACH forms, and more
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.
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
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.
ACH Form
Pay your monthly eternalHealth Medicare Advantage premiums quickly and easily
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.
NOTE: This reimbursement form is for 2023 members only.
Referral Form
Need to see a specialist? Have your Primary Care Provider (PCP) submit the 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.
Summary of Benefits (SoB)
See below for the Summary of Benefits for each of eternalHealth’s four 2023 Medicare Advantage Plans.
2023 eternalHealth Summary of Benefits
Click your plan’s name below to access its related Summary of Benefits (SOB) for 2023:
- 2023 eternalHealth Forever HMO (Last updated April 5th, 2023)
- 2023 eternalHealth ForeverMore HMO (Last updated April 5th, 2023)
- 2023 eternalHealth Freedom PPO (Last updated April 5th, 2023)
- 2023 eternalHealth Give Back PPO (Last updated April 5th, 2023)
2024 eternalHealth Summary of Benefits
Click your plan’s name below to access its related Summary of Benefits (SOB) for 2024:
- 2024 eternalHealth Forever HMO (Last updated September 25th, 2023)
- 2024 eternalHealth ForeverMore HMO (Last updated September 23rd, 2023)
- 2024 eternalHealth Freedom PPO (Last updated September 27th, 2023)
- 2024 eternalHealth Give Back PPO (Last updated September 27th, 2023)
- 2024 eternalHealth Forever HMO (Última actualización el 25 de septiembre de 2023)
- 2024 eternalHealth para siempreMás HMO (Última actualización el 25 de septiembre de 2023)
- 2024 eternalHealth Libertad PPO (Última actualización el 25 de septiembre de 2023)
- 2024 EternalHealth Give Back PPO (Última actualización el 25 de septiembre de 2023)
Evidence of Coverage (EoC)
See below for the Evidence of Coverage for each of eternalHealth’s four 2023 Medicare Advantage Plans.
2023 eternalHealth Evidence of Coverages
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:
- 2023 eternalHealth Forever HMO (Last updated February 14th, 2023)
- 2023 eternalHealth ForeverMore HMO (Last updated February 14th, 2023)
- 2023 eternalHealth Freedom PPO (Last updated February 14th, 2023)
- 2023 eternalHealth Give Back PPO (Last updated February 14th, 2023)
Click your plan’s name below to access its related Evidence of Coverage (EOC) for 2024:
- 2024 eternalHealth Forever HMO (Last updated October 31st, 2023)
- 2024 eternalHealth ForeverMore HMO (Last updated October 30th, 2023)
- 2024 eternalHealth Freedom PPO (Last updated October 30th, 2023)
- 2024 eternalHealth Give Back PPO (Last updated October 11th, 2023)
Annual Notice of Change (ANoC)
See how your plan will change in the coming year.
2023 eternalHealth Annual Notice of Changes
Click your plan’s name below to access its related Annual Notice of Change (ANoC) for 2023:
- 2023 eternalHealth Forever HMO (Last updated February 14th, 2023)
- 2023 eternalHealth ForeverMore HMO (Last updated February 14th, 2023)
- 2023 eternalHealth Freedom PPO (Last updated February 14th, 2023)
Click your plan’s name below to access its related Annual Notice of Change (ANoC) for 2024:
- 2024 eternalHealth Forever HMO (Last updated September 13th, 2023)
- 2024 eternalHealth ForeverMore HMO (Last updated September 13th, 2023)
- 2024 eternalHealth Freedom PPO (Last updated September 13th, 2023)
- 2024 eternalHealth Give Back PPO (Last updated September 13th, 2023)
Formulary
A formulary is a list of generic and brand name prescription drugs that are covered under your health plan.
2023 Formularies
Access the 2023 formulary for the following plans:
- eternalHealth Forever HMO
- eternalHealth ForeverMore HMO
- eternalHealth Freedom PPO
- eternalHealth Give Back PPO
- eternalHealth Forever HMO
- eternalHealth ForeverMore HMO
- eternalHealth Freedom PPO
- eternalHealth Give Back PPO
You can find detailed information about eternalHealth’s prescription drug benefits here.
Over-the-Counter (OTC) Catalog
NOTE: This catalog is for 2023 members only
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.
Note: Use of these catalogs will begin January 1st, 2024.
For 2024, eternalHealth is excited to introduce the OTC and Healthy Grocery Mastercard® Prepaid Flex Card through Nations Benefits! View the catalogs below and be sure to access your member portal here to order your OTC and Healthy Grocery* items, check your OTC balances, and more!
*The healthy grocery benefit is a special supplemental benefit available only to members with eligible chronic health conditions. Not all members will qualify.
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 hesitate to contact eternalHealth.
2023 Low Income Subsidy for Medicare Prescription Drug Coverage
2024 Low Income Subsidy for Medicare Prescription Drug Coverage
eternalHealth Arizona Plan Documents
Personal Forms
We have forms to make every part of your Medicare journey quick and easy. From enrollment forms, the appointment of representative forms, ACH forms, and more!
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 for Arizona
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
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).
ACH Form
Pay your monthly eternalHealth Medicare Advantage premiums quickly and easily
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
Referral Form
Need to see a specialist? Have your Primary Care Provider (PCP) submit the referral form.
Referral Form for American Specialty Health
Need to see a specialist for rehabilitation services? Have your Primary Care Provider (PCP) submit the referral form.
Referral Form for American Speciality Health
Request for Redetermination or Medical Services and Products
If you were denied Medical services or products and would like a redetermination, please complete this form.
Request for Redetermination or Medical Services and Products
Member Complaint Form
We take your concerns seriously – please complete the attached form for any complaints.
Summary of Benefits (SoB)
See below for the Summary of Benefits for each of eternalHealth’s three Medicare Advantage Plans.
- 2024 eternalHealth Horizon HMO (Last updated September 23, 2023)
- 2024 eternalHealth Grand Give Back HMO (Last updated September 23, 2023)
- 2024 eternalHealth Valor Give Back HMO-POS (Last updated October 10, 2023)
- 2024 eternalHealth Horizonte HMO (Última actualización el 23 de septiembre de 2023)
- 2024 EternalHealth Grand Give Back HMO (Última actualización el 23 de septiembre de 2023)
- 2024 eternalHealth Valor Devolver HMO-POS (Última actualización el 10 de octubre de 2023)
Evidence of Coverage (EoC)
Your Evidence of Coverage will provide you with detailed information of 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, to your rights and responsibilities as a member.
- 2024 eternalHealth Horizon HMO (Last Updated October 11th, 2023)
- 2024 eternalHealth Grand Give Back HMO (Last Updated October 30th, 2023)
- 2024 eternalHealth Valor Give Back HMO-POS (Last Updated October 27th, 2023)
Formulary
A formulary is a list of generic and brand-name prescription drugs that are covered under your health plan.
You can find detailed information about eternalHealth’s prescription drug benefits here.
Over-the-Counter (OTC) Catalog
Note: Use of these catalogs will begin January 1st, 2024.
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.
For 2024, eternalHealth is excited to introduce the OTC and Healthy Grocery Mastercard® Prepaid Flex Card Flex Card through Nations Benefits! View the catalogs below and be sure to access your member portal here to order your OTC and Healthy Grocery* items online, check your OTC balances, and more!
*The healthy grocery benefit is a special supplemental benefit available only to members with eligible chronic health conditions. Not all members will qualify.
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 for 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 hesitate to contact eternalHealth.
2024 Low-Income Subsidy for Medicare Prescription Drug Coverage
