MA-PD Member Forms
Get Health First MA-PD member forms and resources.
Prescriptions/pharmacy/authorizations
For more information on filling prescriptions with Health First Family Pharmacy visit Health First Family Pharmacy.
- Request for Medicare Prescription Drug Coverage Determination - if the drug requires prior authorization or an exception, your doctor should submit this form with applicable medical information to our Pharmacy Team for consideration.
- Medical Authorization Request form - for your physician to request authorization for a medical service.
- Request for Redetermination of Medicare Prescription Drug Denial - for members.
- Prescription Drug Reimbursement form.
- Medicare Part D (Hospice) form.
Forms
- Prescription Drug Reimbursement Form (Updated 05/20/2024) — to request reimbursement for a covered prescription if you paid out-of-pocket for it.
- Medical reimbursement form (Updated 9/18/2025) Medical reimbursement form Spanish (Updated 9/18/25) - if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services.
Additional Forms
MAPD Enrollment Request Forms - Use these forms to enroll in our Medicare Advantage plan.
- Brevard - English | Spanish
- Indian River - English | Spanish
- Flagler, Highlands, and Volusia - English | Spanish
- Hardee - English | Spanish
- Hernando, Lake, Orange, Osceola, Pasco, Polk, Seminole - English | Spanish
- Plan Selection Form - For current members to change from one our plan options to another.
- Authorized Representative Form - If you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle release of your information, make changes to your Primary Care Provider, or discuss your Protected Health Information, please complete this form and return to:
Health First Health Plans - Customer Service
6450 US Highway 1
Rockledge, Fl 32955
- Appointment of Representation Form, (updated 07/09/2026). If you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle appeals and grievances with us on your behalf. Once complete, please return to:
Health First Health Plans
6450 US Highway 1
Rockledge, FL 32955
Contact Health First Health Plans
Get in touch with Health First Health Plans for answers, support, and assistance with your coverage.
Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.
Y0089_EL110251_M | Accepted date: 10/01/2025
Last updated: 10/01/2025
*As of 8/1/25 enrollment data. **Other providers available in-network. Health First Commercial Plans, Inc. is doing business under the name of Health First Health Plans. Health First Health Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.