Find a Form

If you are an Elderplan FIDA Total Care (Medicare-Medicaid) participant, your plan  forms are available here.


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.

1-866-360-1934

[TTY 711]

for the hearing impaired

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

Elderplan is available
in the 5 boroughs of NYC,
Nassau, Suffolk, Westchester,
Rockland, Putnam and Monroe counties.

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