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).

Jump to the Items You are Looking For.

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.
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.
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.
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.
Dental Reimbursement Form
Complete and return this form to get paid back for dental services that you paid for yourself.
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.
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.
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.
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)
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:
- 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)
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:
- 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)
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
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.
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 Redetermination Of Medicare Prescription Drug Denial
You may appeal a coverage determination about a prescription drug with this form.
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.
Seeing Some Unfamiliar Words?
We want to give you all the information you need to make the best choices for you and your family.
