Member Handbook and Forms

Member Handbooks

• Integrated Care Program Member Handbook (PDF)
• Family Health Plan Member Handbook (PDF)
• Managed Long Term Services and Supports Member Handbook (PDF)

Forms

• Health Risk Screening Form (PDF)
• Authorization to Disclose Health Information Form (PDF)
• Revocation of Authorization To Disclose Information Form (PDF)
• Authorized Representative Designation Form (PDF)
• Power of Attorney for Healthcare (PDF)
• PCP Change Request Form (PDF)

Additional Resources

• CentAccount Flyer (PDF)
• Office Visit Checklist (PDF) - Use this checklist to get the most out of your PCP visit
• Childhood Wellness Visit (PDF)
• Child Immunization Schedule (PDF)
• Added Benefits (PDF)