Forms and information

Request a Provider and Pharmacy Directory

Complete this form to get a Provider and Pharmacy Directory mailed to you.

Claim form

Request for Payment of Medical Services  (pdf)
Use this form to request repayment of a performed medical service.

Privacy forms

Fallon Health Weinberg is dedicated to protecting privacy. We are strict about who can see member information. However, there may be times when members want to allow certain people (like a caregiver) to see their information. You can use the forms below to grant or deny access to member information.

Medicare's Appointment of Representative form (pdf) (This link takes you away from the Fallon Health Weinberg website.)
This form may be used to appoint someone to handle a grievance or coverage determination, or to deal with any level of the appeal process. Return the completed form to Fallon Health Weinberg, Member Appeals and Grievances, 10 Chestnut St., Worcester MA 01608. 

Amendment Request for Personal Information form  (pdf)
Request changes to a member record if you think it is inaccurate or incomplete. This form is not required for corrections to address, date of birth or name.

Personal Representative Authorization Form - Accessing Personal Information  (pdf)
Identify a personal representative who Fallon Health Weinberg can release your personal information to. Complete a form for each person you want to have as a representative.

Personal Representative Authorization Form - Filing an Appeal  (pdf)
Use this form to authorize someone to file an appeal or grievance on your behalf. Note: This form automatically expires after a year.

Veteran's Office Authorization for Release of Personal Information form  (pdf)
Allow a veteran's office to receive your personal information from Fallon Health Weinberg.

Request for an Accounting of Disclosures of Personal Information form  (pdf)
Request a listing of who Fallon Health Weinberg has shared your information with for reasons other than treatment, payment or health care operations.

Restrictions form  (pdf)
Request a limit on how we use or share your personal information.

Pharmacy forms and information

Appeals and grievances  
This page explains the process for filing an appeal or grievance for issues.

Prior authorization form  (pdf)
This form is filled out by the provider who prescribes drugs that require prior authorization.

Part D appeals form  
Please use this form to initiate a Medicare Part D (prescriptions) appeal.

Request for Medicare Prescription Drug Coverage Determination  (H2470_W_2015_11 Accepted 09262014, pdf)
You or your provider can use this form to request an exception or coverage decision. You can also access an online version of this form, or get the form on the CMS website. (This link takes you away from the Fallon Health Weinberg website.)  

Request for redetermination of Medicare prescription drug denial  (H2470_W_2015_13, Accepted 09262014)
If Fallon Health Weinberg denied a prescription, you can use this form to ask us to change our decision.

 

 

Fallon Health Weinberg is an HMO plan with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Fallon Health Weinberg depends on contract renewal. 

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Fallon Health Weinberg website.)

H2470_W_2017_7 Approved 10182016
The information on this page was last updated on 10/1/2017.

Find a doctor

Looking for a doctor? Need to see if your current doctor is in our network?

Search online

Download the Provider and Pharmacy Directory (H2470_W_2017_26_r1_NM, pdf)

Contact us

Information before enrolling:
1-855-561-7248 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

Customer Service:
1-855-561-7247 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

 

 

Find a doctor

Are you looking for a doctor, hospital, pharmacy, or other community service providers?

Find a doctor online ► or
Download the whole Fallon Health Weinberg-HMO SNP Provider and Pharmacy Directory (H2470_W_2017_26_r1_NM, pdf)

Member information

2017 Summary of Benefits (H2470_W_2017_6_r1 Accepted 10152016) ►

2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf) ►

About the Medication Therapy Management Program

Covered medications

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