Forms and Documents

Prior to downloading your form, please note the following:

  • Forms listed here are in Portable Document Format  (PDF) . You will need Acrobat Reader plug-in to open PDF files. Please visit Adobe website to download the plug-in.
  • After you click on any form, you will be able to see the purpose and requirements of the document. Please take time to read these requirements to check if they are applicable to you. Some of the documents presented here may not apply to you depending on your situation.
  • Some forms may be available for electronic filing.
  • The forms below are not in alphabetical order, please look carefully for the form you require.
  • When a form is due to expire, the form and any changes must be reviewed by the management. If a form expires while it is being reviewed, the form may still be used. Once a new edition is available, the website will be updated to ensure only useable editions are listed.
Last updated: 09/12/2011 2:00:00 PM
Copyright Aultman Health Foundation
AultCare Information Systems
 
 
Miscellaneous
Form Name Description Edition Info Download
form image Access Request Form Access Request Form 1/1/2011 download
form image Accounting Request Form Accounting Request Form 1/1/2011 download
form image Advance Directives Advance Directives Form 1/1/2011 download
form image Amendment Request Form Amendment Request Form 09/09/2011 download
form image Fraud, Waste and Abuse PTHP Fraud, Waste and Abuse download
form image How to Appoint a Representative If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. 12/10/2010 download
form image Notice of Privacy Practices Coverage Determination Form 08/16/2011 download
form image Plan Overview 2012 Plan Overview 2012 09/22/2011 download
form image Provider Directory 2012 Provider Directory 2012 09/20/2011 download
form image Release of Information Form PTHP-Release of Information Form 08/18/2011 download
form image Restriction Request Form Restriction Request Form 1/1/2011 download
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Newsletters
Form Name Description Edition Info Download
form image PTHP Newsletter Fall 2011 Fall 2011 Newsletter 09/15/2011 download
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Quality
Form Name Description Edition Info Download
form image Access to Care Access to Care – PTHP Results 1/1/2011 download
form image Cancer Screening Cancer Screening 1/1/2011 download
form image Cardiac Care Cardiac Care download
form image Customer Service Customer Service 1/1/2011 download
form image Diabetes Care Diabetes Care 1/1/2011 download
form image Getting Care Quickly Getting Care Quickly 1/1/2011 download
form image Getting Needed Care Getting Needed Care 1/1/2011 download
form image How Well Doctors Communicate How Well Doctors Communicate 1/1/2011 download
form image Other Types of Care Other Types of Care 1/1/2011 download
form image Quality Improvement Program Evaluation Evaluation of Primetime Health Plan's quality improvement program for 2009. 3/10/2010 download
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Evidence of Coverage
Form Name Description Edition Info Download
form image Basic MA Evidence of Coverage 2012 Basic MA Evidence of Coverage 2012 download
form image Basic Select Evidence of Coverage 2012 Basic MA Evidence of Coverage 2012 download
form image Plus Evidence of Coverage 2012 Plus Evidence of Coverage 2012 download
form image Premier Evidence of Coverage 2012 Premier Evidence of Coverage 2012 download
form image Prime PPO Evidence of Coverage 2012 Prime PPO Evidence of Coverage 2012 download
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Service Area Maps
Form Name Description Edition Info Download
form image HMO or PPO County Map Coverage Areas/Counties for HMO or PPO PLAN Options 12/17/2009 download
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Prescription Drug Information (Part D)
Form Name Description Edition Info Download
form image 2012 LIS Premium Summary 2012 LIS Premium Summary download
form image Comprehensive Formulary 2012 Comprehensive Formulary 2012 09/28/2011 download
form image Formulary 2011 The formulary document contains information on how it may be changed during the year. 09/09/2011 download
form image Formulary 2012 The formulary document contains information on how it may be changed during the year. download
form image Medical Care, Services, and Payment Medical Care, Services, and Payment 1/1/2011 download
form image Part D Prescription Drugs Part D Prescription Drugs 1/1/2011 download
form image Pharmacy Directory 2012 Pharmacy Directory 2012 09/23/2011 download
form image Physician and Hospital Validation Physician and Hospital Validation 1/1/2011 download
form image Prior Authorization B vs D Criteria and List of Drugs Requiring Prior Authorization B vs. D 10/01/2011 download
form image Quality Assurance Policies and Procedures Includes medication therapy management and drug utilization programs to prevent over and under utilization of prescribed medications to ensure measurements for medication error, reduction of drug interactions and promote member safety. 11/12/2005 download
form image Request for Redetermination MAPD Request for Redetermination MAPD 12/5/2011 download
form image Transition Policy 04/15/2010 download
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Provider Forms
Form Name Description Edition Info Download
form image Prior Authorizations Pharmaceutical Prior Authorizations List 1/1/2011 download
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Summary of Benefits
Form Name Description Edition Info Download
form image Basic MA Only Summary of Benefits 2012 Basic MA Only Summary of Benefits 2012 download
form image Basic Select Summary of Benefits 2012 Basic Select Summary of Benefits 2012 09/22/2011 download
form image Plus Summary of Benefits 2012 Plus Summary of Benefits 2012 download
form image Premier Summary of Benefits 2012 Premier Summary of Benefits 2012 download
form image Prime PPO Summary of Benefits 2012 Prime PPO Summary of Benefits 2012 09/22/2011 download
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Enrollment
Form Name Description Edition Info Download
form image 2012 Enrollment Checklist 2012 Enrollment Checklist 09/22/2011 download
form image 2012 Enrollment Form Addendum 2012 Enrollment Form Addendum download
form image 2012 HMO Enrollment Form 2012 HMO Enrollment Form 09/22/2011 download
form image 2012 PPO Enrollment Form 2012 PPO Enrollment Form 09/22/2011 download
form image Electronic Funds Transfer Form (EFT Form) You may choose to have your monthly premium payment automatically deducted from a checking account. Please complete this form only if you are choosing to have your premium deducted from your bank checking account (EFT option). 1/1/2011 download
form image Enrollment Form Addendum Attestation of Enrollment Eligibility form, certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. 1/1/2011 download
form image Optional Supplemental Benefits Enrollment Form Optional Supplemental Benefits Enrollment Form 09/22/2011 download
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Plan Ratings
Form Name Description Edition Info Download
form image HMO Plan Ratings HMO Plan Ratings 10/1/2011 download
form image PPO Plan Ratings PPO Plan Ratings 10/1/2011 download
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Annual Notice of Change Documents
Form Name Description Edition Info Download
form image Annual Notice of Change - Basic MA 2012 Annual Notice of Change - Basic MA 2012 download
form image Annual Notice of Change - Basic Select 2012 Annual Notice of Change - Basic Select 2012 download
form image Annual Notice of Change - Plus 2012 Annual Notice of Change - Plus 2012 09/20/2011 download
form image Annual Notice of Change - Premier 2012 Annual Notice of Change - Premier 2012 download
form image Annual Notice of Change - Prime 2012 Annual Notice of Change - Prime 2012 download
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