Here you can find links to helpful forms, information and websites. You can also find contact information for agencies, government, local, and national caregiver information and support programs.

Health library

The Healthwise Knowledgebase is Fallon Health Weinberg’s online health library. Members can use our online health library for free. The online library has information on thousands of topics and online health tools

Go to the Healthwise Knowledgebase ► (This link takes you away from the Fallon Health Weinberg website.)

Community resources, government agencies, and caregiver resources and programs

Clicking the links below will cause you to leave the Fallon Health Weinberg website.
This is the official U.S. Government website for the Medicare program. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.
This website is Medicare's free, secure online portal. On this site, you can get information about your Medicare benefits and services.

How do I file a complaint?
This is a page on the official U.S. Government website for the Medicare program. It tells you how to file a complaint if you have a problem with the care or service you get from a Medicare provider.
This site tells you how you can protect yourself from Medicare "scams" and fraud. You can also report a "scam" or fraud through this website.

The Centers for Medicare & Medicaid Services (CMS) -
This is the organization that runs the Medicare and Medicaid programs. Their site gives you answers to common questions and information about important laws.

The Centers for Medicare & Medicaid Services - Best Available Evidence Policy
Information about the CMS Best Available Evidence policy.

Social Security Administration -
This is the official website of the U.S. Social Security Administration. You can also call them at 1-800-772-1213, Monday through Friday, 7:00 a.m. to 7:00 p.m. (TTY: 1-800-325-0778).

New York State Medicaid Program
This is the official website for the State of New York Medicaid Program. You can also call their Helpline at 1-800-541-2831.

New York State Elderly Pharmaceutical Insurance Coverage Program - Health Insurance Information, Counseling and Assistance Program (HIICAP)
This program helps more than 250,000 income-eligible seniors age 65 and older to supplement their out-of-pocket Medicare Part D prescription drug plan costs.

New York State Health Insurance Assistance Program
This is a state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

Americans with Disabilities Act (ADA) (Information and Technical Assistance on the Americans with Disabilities Act)
This website explains what the Americans with Disabilities Act is, who must comply with the ADA and provides other useful information.

PACE4You (National PACE Associate website)
This website explains how Programs of All-inclusive Care for the Elderly (PACE) work and has a tool you can use to find a PACE organization near you.

Family Caregiver Alliance (National Center on Caregiving)
Family Caregiver Alliance supports and sustains the important work of families nationwide caring for loved ones with chronic, disabling health conditions. Their website provides many resources for caregivers.

National Alliance for Caregiving
The National Alliance for Caregiving is a non-profit coalition of national organizations focusing on advancing family caregiving through research, innovation and advocacy. Their website provides many resources for caregivers.

AARP (American Association of Retired Persons) Caregiver Resource Center
Information, tools, tips and expert advice and resources for caregivers


If you're acting as a representative on your loved one's behalf, you may need to submit information to Fallon Health Weinberg. The printable forms below and other information on this page help make that easy.

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.

Appointment of Representative form - PACE (PDF) 
Identify a personal representative who Fallon Health Weinberg can release your personal information to. This form may also 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
Attn: 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  - MLTC (PDF)
Identify a personal representative who Fallon Health Weinberg can release your personal information to. You can also use this form to authorize someone to file an appeal or grievance on your behalf. Complete a form for each person you want to have as a representative.

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

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

Request for Part D appeals form
Please use this form to initiate a Medicare Part D (pharmacy) 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.

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.)

The information on this page was last updated on 1/1/2018.

Ready to enroll?

Talk to one of our Outreach Coordinators about what plan you may be eligible for.

1-716-810-1894 or
1-855-561-7248 (TTY 711),

8:30 a.m.–5 p.m.