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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 customer.service@soundpathhealth.com. 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.

Forms 
& Tools

Reference Information

Rights and Responsibilities Upon Disenrollment View Page
Washington State Advance Directive DOWNLOAD
Silver&Fit®
(By clicking on this link, you will be directed to non-Medicare information.)
VIEW PAGE 
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. 

DOWNLOAD
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
 Download
 
2017 Soundpath Health Medical Prior Authorization Request Form
 Download
 
2017 Soundpath Health Part B Chemotherapy Request Form
 Download
 

Pharmacy Authorization Tools

 
2017 Comprehensive Formulary
Download
 
2017 Prior Authorization Requirements
DOWNLOAD  
2017 Step Therapy Requirements
DOWNLOAD  
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)
 VIEW PAGE 

Claims & Provider Tools

Appeals and Grievances Form Download
New Provider Remittance Advice Definitions DOWNLOAD
Sample CMS-1500 DOWNLOAD
Sample UB-04 DOWNLOAD
Waiver Liability Form Download

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


Page Last Updated: October 17, 2017