Find an Elderplan Form

Elderplan makes it easy to find the information you need.
Please use the links below to access helpful forms.

Information Update Form: English | Español

Member Reimbursement Form: English | Español

Member Part D Reimbursement Form: English | Español

CVS Mail Service Order Form: English | Español

Request for Redetermination of Medicare Prescription Drug Denial: English | Español

Authorization for Release of Health Information Pursuant to HIPAA: English | Español

To request a Part D Coverage Determination for Elderplan Members Only: English | Español

Medicare Electronic Complaint Form: English | Español

Appointing a Representative:

How to Appoint a Representative

Appointment of Representative: English | Español

Questions? Call Elderplan today.


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Hours of Operation:
8 a.m. to 8 p.m., 7 days a week

Elderplan is available in the 5 boroughs of NYC, Nassau, Suffolk, Westchester, Rockland, Putnam, Monroe, Dutchess, Orange, Ontario, Orleans, Seneca, and Yates counties.

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