Senior Health Plan (HMO)
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2025 Medical & Prescription Plans

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Forms and Documents

Use the links below to access some of the important Senior Health Plan forms. If you can't find the form you're looking for, please contact us for assistance.

Enrollment

  • Pre-Enrollment Checklist
  • Individual Election Formupdated 06/12/2025
  • Plan Change Formupdated 01/24/2025
  • Request for Disenrollmentupdated 05/28/2026

Manage Plan

  • Auto Bank Draft Authorization
  • SSA/RRB Withhold Form
  • Protected Health Information (PHI) Authorization Formupdated 08/13/2026
  • Member Request to Access Protected Health Information
  • Primary Care Physician (PCP) Change Form
  • Appointment of Representative Form
  • Oklahoma Advance Directive for Health Care
  • Alternate Contact
  • Continuity of Care Program

Claims, Authorizations and Appeals

  • Claim Form
  • Part C Authorization Request Form
  • Coverage Determination Request Form
  • Part C Appeal Request Formupdated 05/14/2026
  • Part D Appeal Request Formupdated 02/06/2025

Health and Wellness

  • Annual Care Checklistupdated 11/22/2024
  • Medication Log
  • Fall Safety Checklist
  • Blood Pressure Log
  • Blood Pressure Brochure
  • Text Campaign
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Everything You Need to Know About CommunityCare Medical & Prescription Plans

  • Find helpful information in Important Resources .
  • Find out about Upcoming Seminars.
  • Find upcoming events at our Senior Center.
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Senior Health Plan is an HMO plan and a D-SNP plan with a Medicare & Medicaid contract. Enrollment in Senior Health Plan depends on contract renewal.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact www.medicare.gov or 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. Medicare customer service representatives are available 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

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  • Updated: 03/20/2025
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