Helpful documents
Listed below are documents that will help you make the right health care choice for you. Simply click on the links below to download each document you are interested in.
Summary of Benefits
A summary of benefits is a booklet that compares our benefits with Original Medicare benefits.
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.
Low-income subsidy premium chart
If you qualify for extra help with your Medicare prescription drug plan costs, your premium and drug costs will be lower.
Medication Therapy Management Program
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. Download the brochure for more information.
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 below 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.
Other helpful documents
Health care proxy form (pdf, 27 KB)
With this form, you may give legal authority to your health care agent to make all health care decisions on your behalf, if you become incapable of making such decisions for yourself.
Personal Wishes Statement (pdf, 25 KB)
This form offers guidance for your health care agent if he or she needs to make decisions about your care.
Fallon Senior Plan Preferred and Fallon Senior Plan Premier Preferred Reimbursement Form (pdf, 312 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 2007 and 2008.
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, 63 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, 63 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.
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