Forms and Documents

Use the links below to access some of the important Senior Health Plan forms. If you can't find the form you're looking for, please contact us for assistance.

Enrollment

• Pre-Enrollment Checklist
• Individual Election Form
• Plan Change Form
• Request for Disenrollment

Manage Plan

• Auto Bank Draft Authorization
• SSA/RRB Withhold Form
• Protected Health Information (PHI) Authorization Form
• Member Request to Access Protected Health Information
• Primary Care Physician (PCP) Change Form
• Oklahoma Advance Directive for Health Care
• Appointment of Representative Form
• Alternate Contact
• Continuity of Care Program

Claims, Authorizations and Appeals

• Claim Form updated 10/12/2023
• Part C Authorization Request Form - updated 9/26/2019
• Coverage Determination Request Form
• Part C Appeal Request Form - updated 9/30/2022
• Part D Appeal Request Form - updated 9/30/2022

Health and Wellness

• Preventive Services Checklist
• Medication Log
• Fall Safety Checklist

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Everything You Need to Know About CommunityCare Senior Health Plan

Find helpful information regarding our Senior Health Plan in the Senior Health Plan Forms & Resources section. You can find information on our upcoming seminars by clicking the Seminar Schedule link below. Open the Tulsa Area Social Classes Schedule below to see upcoming events.

If you have questions about joining Senior Health Plan, call our Sales & Marketing Team at (918) 594-5275, Monday through Friday from 8:00 am to 6:00 pm.

If you are a current member, please call Customer Service at (918) 594-5323. We are available Monday through Friday from 8:00 am to 8:00 pm. From October 1 through March 31, our hours include Saturdays, Sundays and some holidays.

TTY/TDD users should call 1-800-722-0353.

If you would like to contact Senior Health Plan via mail, please use the following address:

Senior Health Plan Customer Service
P.O. Box 3327
Tulsa, OK 74101-3327

You can also get information about the Medicare program and Medicare health plans by visiting www.medicare.gov on the Web or by calling 1-800-MEDICARE (1-800-633-4227). Medicare customer service representatives are available 24 hours a day, 7 days a week to answer questions about Medicare. TTY/TDD users should call 1-877-486-2048.

• Information regarding multi-language interpreter services.
• Medicare & You
• Disclaimers

• Gramm-Leach Bliley Act (Consumer Information Disclosure)
• HIPAA Notice of Privacy Practices - updated 10/2022
• Protected Health Information (PHI) Authorization Form
• Nondiscrimination Notice
• Compliance and Code of Excellence
• Website Privacy Statement
• Network Opt-Out Request Form