Other Coverage Questionnaires
Designated Representative Authorization Questionnaires
Senior Preferred Forms
- To request an initial Part D coverage determination or exception, please use this form:
- To request a Part D redetermination, first-level appeal, please use this form:
- Appointment of Representative Statement form (If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal or grievance, please refer to this form).
Senior Choice Forms
Completed forms can be mailed or faxed to:
Gundersen Health Plan
Mail stop: NCA2-01
1900 South Avenue
La Crosse, WI 54601
Fax: (608) 775-8091
This web page was last updated on June 5, 2015.