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).

Documents for 2022 eternalHealth Massachusetts Plans

Summary of Benefits (SoB) See below for the Summary of Benefits for each of eternalHealth’s three Medicare Advantage Plans 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. Formulary Available for Download You can find detailed information about eternalHealth’s prescription drug benefits here.

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 or grievance process.

Advance Directives Information

Plan Forms

2022 Enrollment Form 

2022 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). Above is the link to the necessary form.

Fitness Reimbursement Form 
Complete and return this form to get paid back for staying healthy with any gym, group fitness class, or your favorite online class subscription.

Direct Member Reimbursement Form 
Complete and return this form to get paid back for medical services or medications that you paid for yourself.

Prior-Authorization Form 
Your provider can file a request on your behalf, or you may also submit a request.

Referral Form
Need to see a specialist? Have your Primary Care Provider (PCP) submit the referral form.

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 hesitate 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. Take a look at our handy vocabulary list here.

Wide Orientation

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Page Last Updated On: May 5, 2022