Member Materials and Forms

Here you can find important documents about your Senior Whole Health plan. Click the links below to view or download member materials, forms, and newsletters specific to your plan.

Member Forms

Click on the links below to access important member forms.

Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

Appointment of Representative Form (CMS-1696)

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Senior Whole Health at:

Molina Healthcare
ATTN: Service Fulfillment
200 Oceangate Ste 100
Long Beach, CA 90802-9957

Coverage Determination Request Form – Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy.

You may submit your Coverage determination request form here online.

You may also complete the below form and mail or fax.

2025 Senior Whole Health (HMO D-SNP)

2025 Senior Whole Health NHC (HMO D-SNP)

Address:		Senior Whole Health 7050 S Union Park Center Drive, Suite 600 Midvale, Utah 84047

Fax:		(866) 290-1309

How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal

2025 Senior Whole Health (HMO D-SNP)

2025 Senior Whole Health NHC (HMO D-SNP)

Redetermination Form - Use this form to request a redetermination (appeal). You may submit your Redetermination request form here online.

You may also complete the below form and mail or fax.

2025 Senior Whole Health (HMO D-SNP)

2025 Senior Whole Health NHC (HMO D-SNP)

Complete this form and mail or fax to:

Address:		7050 S Union Park Center Drive, Suite 600 Midvale, Utah 84047

Fax:		(866) 290-1309

General Direct Member Reimbursement Form - Use this form to request a reimbursement for something you paid out of pocket for but believe should have been covered by your health plan. Members who qualify for Special Supplement Benefits for the Chronically III (SSBCI) should use this form for utility reimbursement requests.

General Direct Member Reimbursement Form for Senior Whole Health HMO D-SNP plans

Pharmacy Direct Member Reimbursement Form - Use this form to request a reimbursement for prescriptions you paid out of pocket for but believe should have been covered by your plan.

2025 Senior Whole Health (HMO D-SNP)

2025 Senior Whole Health NHC (HMO D-SNP)

Grievance and Appeal forms & the Medicare.gov Complaint Form

Advance Directives Information Sheet: provides insight on Advance Directives.

Advance Directives Information Sheet

Disenrollment form and process

You may disenroll from our plan at any time because you are covered by Medicare and/or MassHealth Standard (Massachusetts Medicaid).

Print the PDF form. Fill it out in black/blue ink and sign the form. Mail, fax, or email using the directions on the form.

Disenrollment form (PDF)

For more information, or if you have questions, please call Member Services.

Adobe Acrobat Reader is required to view the files above. Download a free version.

*Printed copies of information posted on our website are available upon request.

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