Forms
- Authorization of Personal Representative
- Enrollment
- Additional Benefits – Allowance Programs Reimbursement
- Electronic Funds Transfer (EFT) Authorization
- Mail Order
Authorization of Personal Representative Form
If you would like to authorize someone else to call HNE and discuss your personal health information, please complete and mail form to the address below. (Please note: the authorization is valid only if signed.)
HNE Medicare Advantage Plan
Enrollment Department
One Monarch Place
Springfield, MA 01144-1500
You may also use the CMS Appointment of Representative Form to appoint someone to represent you in requesting an initial organization or coverage determination or in filing a grievance or appeal. Mail completed forms to the above address.
You may revoke an authorization or end an appointment at any time by sending us a letter to the same address. Please include your name, address, member identification number and a telephone number where we can reach you.
Enrollment Form and Instructions (click this link to go to the page that includes the enrollment form and instructions)
If you would like to enroll in one of our Medicare Advantage plans, please complete and mail form to the address below. You may also enroll online by clicking Enroll Now!
HNE Medicare Advantage Plan
Enrollment Department
One Monarch Place
Springfield, MA 01144-1500
Additional Benefits – Allowance Programs Reimbursement Form (H8578_2012_037 CMS Approved 09/16/2011)
HNE offers some additional benefits including our allowance programs. As a member you are eligible to be reimbursed:
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$150 per calendar year for joining a Fitness Club or Weight Watchers® or for certain Safety Items
-
$150 per calendar year for any Dental Services with any dental provider
-
$100 every two calendar years for prescription eye wear
- $350 per year for a wig if you are on or recently undergone chemotherapy
Review the brochure attached to the form (see link above) for more details on these and other additional beneftis.
Please send the form with receipts to the address below.
HNE Medicare Advantage Plan
Claims Department
One Monarch Place
Springfield, MA 01144-1500
Electronic Funds Transfer (EFT) Authorization Form
If you would like to pay your monthly premium as an EFT withdrawal from your checking or savings account, please print, complete, and mail or fax this form to HNE Medicare Advantage.
HNE Medicare Advantage Plan
Accounting Department
One Monarch Place
Springfield, MA 01144-1500
Fax #: 413-233-2730
If you would like to obtain prescription drugs via mail order, please use this form.
To obtain a paper copy of any of these forms, please call Member Services at the number listed below.
