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Soundpath Health Forms & Tools

Soundpath Health Customer Service Representatives are available to assist you Monday through Friday from 8 am - 8 pm. We are also available to answer your questions via email at To reach us by phone, please contact us toll free at 1-866-789-7747 (TTY 711).Our hours of operation are 8 am - 8 pm, Monday through Friday and 8 am - 8 pm, Saturday and Sunday from October 1 through February 14.

& Tools

Reference Information

Rights and Responsibilities Upon Disenrollment View Page
Washington State Advance Directive DOWNLOAD
(By clicking on this link, you will be directed to non-Medicare information.)
2018 Star Ratings Information  DOWNLOAD 
2017 Star Ratings Information DOWNLOAD
Authorization to Disclosure Protected Health Information DOWNLOAD

CMS Appointment of Representative Form

To appoint someone to act on your behalf, please complete this form and return it to the plan.
This link will take you to a new website. 

Notice of Privacy Practices DOWNLOAD
Multi-Language Sheet DOWNLOAD
Member Emergency Information DOWNLOAD

Other Forms

2017 Enrollment Form DOWNLOAD
2017 Plan Change Enrollment Form DOWNLOAD
Scope of Appointment  DOWNLOAD
Premium Payment Form Download
Prescription Drug Reimbursement Request Form DOWNLOAD
VSP Reimbursement Form DOWNLOAD

Mail Order Forms

2017 Prescription Mail Order Form (from WellDyneRx) DOWNLOAD
2017 Prescription Mail Order Form (from Wellpartner) DOWNLOAD
2017 Prescription Mail Order Form (from PPS) DOWNLOAD
2017 Prescription Mail Order Form (from Walgreens) DOWNLOAD

Medical Referrals & Authorizations

POD1/PSW Part B Prior Authorization Form DOWNLOAD
2017 Medical Prior Authorization and Notification List
2017 Soundpath Health Medical Prior Authorization Request Form
2017 Soundpath Health Part B Chemotherapy Request Form

Pharmacy Authorization Tools

2017 Comprehensive Formulary
2017 Prior Authorization Requirements
2017 Step Therapy Requirements
2017 Soundpath Health Pharmacy Part D Coverage Determination Request Form DOWNLOAD
2017 Soundpath Health ONLINE Pharmacy Part D Coverage Determination Requests through MedImpact 
(Note: This link will direct you to a non-Medicare website)

Claims & Provider Tools

Appeals and Grievances Form Download
New Provider Remittance Advice Definitions DOWNLOAD
Sample CMS-1500 DOWNLOAD
Waiver Liability Form Download

 Provider change form
 Provider termination form 
 Add New Provider to Current Provider Participation Agreement
 Soundpath Health Provider Manual

Page Last Updated: October 17, 2017