All the plan forms and documents provided here are also available by calling Member Services at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week.  The forms below are available as a PDF file. We can also provide member materials in other languages or formats, like Braille or large print.  Please contact member services for more information.

You will need Adobe Reader to view these files; this is available free of charge at Adobe’s site.

Member Materials (2015)

Member Materials (2016)

Appointment of Representative

An authorized representative is the person you designate to assist or handle affairs related to your health care services. This may be someone you designate as a Power of Attorney, a family member, friend, caregiver, or an advocate you assign to assist with an exception, appeal or grievance.

To become an authorized representative, you’ll need to download and print the Appointment of Representative Form. Both you and the person you wish to represent will need to sign the form.

Medicare Part D Forms

Other Forms and Documents

  • Prior Authorization Form (Medical)
  • Member Appeal Request Form – is available to you to fill out if you got a Notice of Action letter from Advicare and you disagree with the action we took. You may complete this form to ask for an Appeal. Remember, you must ask for an Appeal within 90 calendar days from the date on the Notice of Action letter. You may send the completed form back to Advicare via fax, email, or regular mail.
  • Patient Consent for Provider to file an Appeal – A provider must have a member’s written consent in order to file an appeal on their behalf.  This form may be used to obtain consent and should be sent back to Advicare via fax, email, or regular mail.
  • Personal Representative Form – You may designate a personal representative who will act on your behalf in making decisions related to health care, which includes treatment and payment issues. This individual can be a family member, friend, lawyer, or unrelated party.  You may complete this form and send back to Advicare via fax, email, or regular mail.

Disclaimer

Advicare Advocate (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees. This information is available in other formats, such as Braille, large print, and audio. This information is also available for free in other languages.  Please call our customer service number at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. The call is free.

Esta información está disponible de forma gratuita en otros idiomas. Por favor llame a nuestro número de atención al cliente al 1-844-564-0143 (TTY/TDD 711 o 1-888-357-7188), 8:00 a.m. hasta las 8:00 p.m., los siete días de la semana. La llamada es gratuita.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply.  For more information, call Advicare Advocate Member Services or refer to the Advicare Advocate Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year.

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Plans are available in the following counties: Abbeville, Aiken, Allendale, Anderson, Bamberg, Barnwell, Berkeley, Beaufort, Calhoun, Charleston, Cherokee, Chester, Chesterfield, Clarendon, Colleton, Dillon, Dorchester, Edgefield, Fairfield, Florence, Georgetown, Greenville, Greenwood, Hampton, Jasper, Kershaw, Laurens, Lee, Lexington, Marion, Marlboro, McCormick, Newberry, Oconee, Orangeburg, Pickens, Richland, Saluda, Spartanburg, Union, Williamsburg.

Page Last Updated: January 21, 2016