Plan Documents

To view, download, and/or print additional details about Clover Health plans, click on the link below, enter your zip code and select your plan

Summary of Benefits, Evidence of Coverage (EOC), and Annual Notice of Change (ANOC).

2025 2026

Forms & Policies

You can view and download important forms and policies related to your plan.

Sharing Health Information Forms

Click below to access the forms that authorize the sharing of your Protected Health Information (PHI). Each form will have instructions on how to submit.

Use this form allow people like your spouse, child, other family member or trusted friend, to discuss your health insurance benefits or healthcare with Clover representatives.

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Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request. By signing this form and appointing this representative, you agree that the representative will be the main contact and have authority to make requests, present evidence, get information, and receive all communication about your action. This person may see your personal medical information.

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Use this form to ask Clover Health to use different contact information, such as a phone number, mailing address, email address, or another method(s) of contact, when we communicate with you about your PHI.

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Use this form to ask for a copy of your PHI from Clover Health to be sent to you or to another person, such as a family member. These records include medical and billing records.

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Use this form to request a report called an “accounting of disclosures” that tells you when and why your PHI was shared for certain purposes.

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Use this form to request a correction (amendment) to the information in your health records that are maintained by Clover Health.

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Use this form to ask Clover Health to restrict the use or disclosure of your PHI for certain aspects of treatment, payment, or healthcare operations.

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Billing and Reimbursement Forms

Click below to access forms for billing and reimbursements. Each form will have instructions on how to submit.

Use this form to authorize Medicare to automatically deduct your monthly premiums from your bank account.

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A Part D Late Enrollment Penalty (LEP) Reconsideration Request form is used to challenge a late enrollment penalty assessed on a Part D prescription drug plan. Use this form to appeal the penalty if you believe it's incorrect or if extenuating circumstances apply, such as having continuous creditable coverage or experiencing a medical emergency that prevented timely enrollment.

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Use this form to request reimbursement for out-of-pocket expenses for treatments that are covered under your Medicare plan but were not paid for by your Medicare plan.

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Use this form to request reimbursement for out-of-pocket expenses for medications that are covered under your Medicare plan but were not paid for by your Medicare plan.

Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).

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