Find an Elderplan Form

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

Elderplan Enrollment Form
Member Information Update Form
Member Reimbursement Form
Prescription Reimbursement Claim Form
Prescription Drug Mail Order Form
Redetermination of Prescription Drug Denial Form
Authorization for Release of Health Information

Request For Part D (Prescription Drug) Coverage

Medicare Electronic Complaint Form: English | Español

Appointing a Representative:

How to Appoint a Representative

Appointment of Representative

Contact Member Services 

If you are an Elderplan Member and have questions or concerns, please don’t hesitate to contact Elderplan Member Services at 1-800-353-3765 [TTY: 711], 8 a.m. to 8 p.m., seven days a week.

For additional information on how to get in touch with us, visit our Member Services Page.

Want to become an Elderplan member?

Call our Enrollment Call Center at
1-866-360-1934 [TTY: 711]
8 a.m. to 8 p.m., 7 days a week or enroll online.