University of Maryland Health Advantage > For Members > Medical Forms

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Medical Forms

Appointment of Representative Form	Use this form to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions and/or Appeals.
Member Medical Reimbursement Form	Return the completed form and applicable receipts to the address for your health plan listed in the attached document.
PCP Change Request Form	You can use this form to request a change in your Primary Care Physician (PCP) Fax to: 1-844-329-1085 Mail to: CareFirst BlueCross BlueShield Medicare Advantage Attention: Enrollment Department PO Box 915 Owings Mills, MD 21117
Request for a Reconsideration (Appeal)	Use this form to request an appeal of CareFirst Medicare Advantage’s denial of coverage and/or payment of medical and/or hospital services