If you do not already have another person authorized under state law to act for you, and you want someone to act for you as your appointed representative, then you and the person you want to act for you must sign and date a statement that gives this person legal permission to act as your representative. You can name a relative, friend, advocate, doctor, or someone else to act on your behalf.

You may use the Medicare Appointment of Representation Form which must be mailed to us at the address on the bottom of the screen or faxed to 318-361-2170 (available 24 hours per day)

To request a coverage determination, you may use:

for general users:
Model Coverage Determination Request Form

for doctors:
Model Coverage Determination Request Form for Physicians

for prescriptions:
Medicare Prescription Drug Determination Form

 

Evidence Of Coverage

   Vantage Premium Plan (AAA3)

   Vantage Zero Plan (AAA0)

   Vantage Value Plan (AAA1)

   Vantage Traditional Plus (AAA4)

   Vantage Capitol Plan (AAA6)