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Information from your health plan about COVID-19 (coronavirus disease)

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Medicare document library

 We try to minimize paperwork. But sometimes you need a form or other information. And when you need it, you want it to be convenient. We have created a document library to give you easy access to the most requested forms. Select your plan below.
  • 2021 Assurance Rx Annual Notice of Changes

    A letter sent in September 2020 to inform members about plan changes effective Jan. 1, 2021

    Download

  • 2021 Assurance Rx Evidence of Coverage

    The comprehensive booklet that details the services Assurance Rx HMO-POS plan covers, what the member pays, and plan rules

    Download

  • 2021 Delta Dental Preventive Certificate

    The booklet that explains the preventive dental coverage provided at no charge to the member

    Download

  • 2021 Medicare Advantage Customer Guide - South

    A brochure that explains Medicare Advantage HMO-POS plans, including the costs, benefits and coverage provided beyond Original Medicare

    Download

  • 2021 Medicare Advantage HMO/D-SNP Star Rating

    A sheet that explains the Centers for Medicare and Medicaid Services (CMS) Star Rating achieved by Security Health Plan’s HMO-POS and D-SNP plans

    Download

  • 2021 Medicare Advantage HMO-POS Abridged Formulary

    A list of the most common prescription drugs available to members of a Medicare Advantage HMO-POS plan from Security Health Plan

    Download

  • 2021 Medicare Advantage HMO-POS Comprehensive Formulary

    A comprehensive list of all prescription drugs available to members of a Medicare Advantage HMO-POS plan from Security Health Plan

    Download

  • 2021 Medicare Advantage HMO-POS Drug Prior Authorization List

    A list of prescription drugs available with prior approval to members of a Medicare Advantage HMO-POS plan from Security Health Plan

    Download

  • 2021 Medicare Advantage HMO-POS Enrollment form - South

    Use this form to request enrollment in a Medicare Advantage HMO-POS plan from Security Health Plan

    Download

  • 2021 Medicare Advantage HMO-POS Pre-enrollment Checklist

    Information for potential members to understand the benefits and rules of a Medicare Advantage HMO-POS plan

    Download

  • 2021 Medicare Advantage HMO-POS Short Enrollment form - South

    Use this form to request a plan change from one Security Health Plan Medicare Advantage plan to another

    Download

  • 2021 Medicare Advantage HMO-POS Summary of Benefits - South

    A summary document that details the services a Medicare Advantage HMO-POS plan from Security Health Plan covers and what the member pays

    Download

  • 2021 Medicare Advantage Member Handbook

    “Quick start” guide that explains key benefits and other information to help members use their health plan to the fullest

    Download

  • 2021 Medicare Advantage Pharmacy Directory

    The detailed list of all pharmacies in the network for Security Health Plan’s HMO-POS and D-SNP plans

    Download

  • 2021 Medicare Advantage Provider Directory - North/South

    A list of all health care providers and facilities included in the network for Security Health Plan’s Medicare Advantage north and south regions

    Download

  • 2021 Medicare Advantage Provider Directory - North/South - Addendum

    Monthly updates to the list of health care providers and facilities available in your Medicare Advantage network

    Download

  • Appointment of Representation Form

    Names a legal representative to receive health information and act on the member’s behalf in regards to a claim, appeal or grievance

    Download

  • Assurance Rx Verificación de cobertura de 2021

    El folleto completo que detalla lo que cubre el plan Assurance Rx HMO-POS, lo que paga el miembro y las reglas del plan

    Download

  • HIPAA Authorization to Use and Disclose Protected Health Information

    Use this form to designate individuals you choose to have access to your health information

    Download

  • Medicare Advantage Automatic Premium Payment Plan

    Use this fillable form to sign up for automatic payment of your Medicare Advantage monthly premium

    Download

  • Medicare Advantage Member Prescription Drug Reimbursement Request

    Use this form to request reimbursement for prescription drugs you paid for that are covered under your Part D benefits

    Download

  • Medicare Advantage Request for Disenrollment

    Form used to request disenrollment from a Medicare Advantage plan

    Download

  • Medicare Complaint Form

    Used to submit a complaint or concern about your Medicare health plan directly to the Centers for Medicare & Medicaid Services

    Download

  • Medicare Coverage Inquiry

    Form provider uses to request coverage when a member’s treatment or service requires prior authorization by Security Health Plan

    Download

  • National Coverage Determination

    Periodic updates from the Centers for Medicare & Medicaid Services for new covered services, treatment and procedures

    Download

  • Other insurance information

    Form to indicate insurance coverage a potential member may have in addition to their Medicare Advantage plan from Security Health Plan

    Download

  • Part D Vaccine Reimbursement Request form

    Use this form to request reimbursement for vaccines you paid for that are covered under your Part D prescription drug benefits

    Download

  • SilverSneakers Brochure

    Flyer that describes the SilverSneakers fitness benefits offered free of charge to Security Health Plan’s HMO-POS and D-SNP members

    Download

Security Health Plan and its agents are not in any way connected with the Medicare program.
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