Helpful documents
Simply click on the links below to download each document you are interested in.
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Summary of Benefits
A summary of benefits is a booklet that compares our benefits with Original Medicare benefits.
Benefits-at-a-glance and Quick reference guides for our:
Evidence of Coverage
An evidence of coverage is a booklet that we provide once you become a member. It’s part of your contract with us and it describes your complete benefits as well as how to use the plan.
Other documents
Medicare 101 (pdf, 138 KB)
Our easy-to-follow "Medicare as easy as 1-2-3" guide gives you a high-level primer on Medicare.
Medication Therapy Management Program (pdf, 37 KB)
A Medication Therapy Management (MTM) Program is a free service that we may offer through Fallon Senior Plan. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected.
Fallon Senior Plan Preferred and Fallon Senior Plan Premier Preferred Reimbursement Form (pdf, 57 KB)
Fallon Senior Plan Preferred members use this form for reimbursement for out-of-network Weight Watchers®, health/wellness education classes or services (health education classes, nutritional training and smoking cessation) for 2008 and 2009.
Member rights and responsibilities (pdf, 40 KB)
This document explains your rights and responsibilities as a Fallon Senior Plan member.
Appeals, grievances and exceptions for Medicare Part D (pdf, 62 KB)
This document explains the process for filing an appeal or grievance for drugs covered under Medicare Part D, and how to request an exception to the formulary as a Fallon Senior Plan member.
Appeals and grievances (non-Part D) (pdf, 58 KB)
This document explains the process for filing an appeal or grievance for all other issues not related to Medicare Part D as a Fallon Senior Plan member.
Prior authorization form (pdf, 70 KB)
This form may be filled out by the provider who prescribes your drugs that require prior authorization.
Request for Medicare prescription drug coverage determination form
Use this form for you to request an exception or coverage determination.
Medicare Part D coverage determination request form
The provider who prescribes your drugs may use this form to request an exception or coverage determination.
CMS' Appointment of Representative form
This form may be used to appoint someone to handle a grievance, coverage determination, or in dealing with any level of the appeal process.
Privacy forms
Because Fallon Community Health Plan is dedicated to protecting your privacy, we are strict about who can see your information. However, there may be times that you want to allow certain other people to see your information or perhaps get a copy for yourself. FCHP makes this easy for you to do by printing off the appropriate form and submitting it according to the directions on the form.
Amendment Request for Personal Information form
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.
Authorization for Release of Personal Information form
Allow another individual/entity to receive your personal information from FCHP (such as your employer, if they are working on your behalf to resolve a claim issue).
Veteran’s Office Authorization for Release of Personal Information form
Allow a veteran’s office to receive your personal information from FCHP.
Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Community Health Plan’s notice of privacy practices.
Personal Representative Authorization form
Identify a personal representative—someone FCHP can release your personal information to. Complete a form for each person you want to have as a representative.
Request for an Accounting of Disclosures of Personal Information form
Request a listing of who FCHP has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.
Restriction form
Request a limit on how we use or share your personal information.
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