Member Forms
Enrollment / Disenrollment
- 2024 Enrollment Form – Central Ohio. Use this form to enroll in a Mount Carmel MediGold plan if you live within the Central Ohio service area.
- 2024 Enrollment Form – Northwest Ohio. Use this form to enroll in a Mount Carmel MediGold plan if you live within the Northwest Ohio service area.
- 2024 Enrollment Form – Southwest Ohio. Use this form to enroll in a Mount Carmel MediGold plan if you live within the Southwest Ohio service area.
- Dental Disenrollment Form. Use this form to disenroll from your optional supplemental dental plan. Note: You may disenroll from a supplemental dental plan without ending your membership in Mount Carmel MediGold.
- Disenrollment Form. Use this form to disenroll from Mount Carmel MediGold.
Legal
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Advanced Directive. Use this form to give instructions for your health care in the event that you are no longer able to make or communicate those decisions yourself.
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CMS Appointment of Representative Form. Use this form to appoint someone to represent you on formal matters, such as appeals or grievances.
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Release of Information Form. Use this form to allow loved ones to access your protected health information.
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VA Release of Information Form. Use this form to authorize the Department of Veteran's Affairs to release health-related information to those you designate.
Prescription Drugs
- CVS Caremark Prescription Mail Order Form. Use this form to start mail-order pharmacy services.
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Request for Medicare Prescription Drug Coverage Determination. Use this form to request a coverage determination or exception to our drug formulary.
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Request for Redetermination of Medicare Prescription Drug Denial. Use this form to file an appeal related to your Part D prescription drug benefits.
Prior Authorization
- Prior Authorization Form. You or your provider can use this form to request prior authorization for services that require it.
Reimbursement
- CVS Caremark Drug Claim Form. Use this form to be reimbursed for out-of-pocket covered prescription medication.
- Direct Member Reimbursement Request Form. Use this form to request reimbursement for glasses after cataract surgery or other allowable medical expenses.