Aspire Health PlanCommercial Clinical Policy

Authorization Request Form Form

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Authorization Request Form

Indications

(1) Why Aspire Health? 
(2) Am I Eligible for Medicare? 
(3) Already have a Power of Attorney (POA)? Make sure it’s Valid? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



Authorization Request Form (PDF)

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Documents and Resources

2026 Plan Documents

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2026 Plan Documents

The following documents provide important information on services and benefits to help you make an informed decision about enrolling.

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2026 Forms

Enrollment Forms

Member Forms

Documents

  • All-in-One Medicare Advantage Decision Guide (PDF):  English   |  Español

  • Benefit Highlights Brochure (PDF):  English   |  Español

  • Enhanced Benefits – Dental, Vision and Hearing (PDF): English   |   Español

  • Medicare Star Ratings (PDF): (Last Revised 10/2025)   English   |   Español

  • Notice of Availability (PDF)

  • Non Discrimination Notice (PDF):  English   |  Español

  • Summary of Benefits (PDF): (Last Revised 9/2025)   English   |  Español

Annual Notice of Change

  • Aspire Health Advantage (HMO) – Annual Notice of Change (PDF):  (Last Revised 9/2025)    English   |  Español

  • Aspire Health Plus (HMO-POS) – Annual Notice of Change (PDF): (Last Revised 9/2025)     English   |  Español

  • Aspire Health Value (HMO) – Annual Notice of Change (PDF):  (Last Revised 9/2025)   English   |  Español

  • Aspire Health Group Plus (HMO-POS) – Annual Notice of Change (PDF):  (Last Revised 9/2025)   English |  Español

  • Aspire Health Protect (HMO) – Annual Notice of Change (PDF): (Last Revised 9/2025)    English   |   Español

Evidence of Coverage

  • Aspire Health Advantage (HMO) – Evidence of Coverage (PDF): (Last Revised 9/2025)   English   |  Español

  • Aspire Health Plus (HMO-POS) – Evidence of Coverage (PDF):  (Last Revised 9/2025)  English   |  Español

  • Aspire Health Value (HMO) – Evidence of Coverage (PDF):  (Last Revised 9/2025)   English   |  Español

  • Aspire Health Group Plus (HMO-POS) – Evidence of Coverage (PDF): (Last Revised 9/2025)   English |  Español

  • Aspire Health Protect (HMO) – Evidence of Coverage (PDF):  (Last Revised 9/2025)   English   |  Español

Provider Directory

  • Provider and Pharmacy Directory (PDF): (Last Revised 5/2026)    English   |   Español

If you would like to request a mailed copy of the current Provider and Pharmacy Directory, or if you need help finding a network provider and/or pharmacy, please call member services toll-free at (855) 570-1600 (TTY 711)

Enrollment Forms

  • Aspire Health Plan Enrollment Form (PDF):  English   |  Espa ñ ol

  • Enhanced Benefits Enrollment Form (PDF):  English   |   Español

  • Scope of Appointment Form (PDF):  English   |   Español

Member Forms

  • Aspire Health Plan Disenrollment Form (PDF): English   |   Español

  • Appeal and Grievance Form (PDF):  English   |   Español

  • Authorization Request Form (PDF):   English   |   Español

  • Claim Reimbursement Request Form (PDF):   English   |   Español

  • Electronic Funds Transfer Form (PDF):    English   |   Español

  • Enhanced Benefit Disenrollment Form 2026 (PDF):  English   |   Español

  • Prescription Drug Coverage Determination (PDF): (Last Revised 9/2019)    English   |   Español

  • Prescription Drug Reimbursement Form (PDF): English   |  Español

  • Prescription Redetermination Request (PDF):   English   |   Español

  • Plan Change Form 2026 (PDF):  En g lish   |   Español

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Care in an Emergency or Disaster

Getting medical care & prescription drugs in disaster or emergency areas

If the Governor of California, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in Monterey County, you can still get medical care and prescription medications from Aspire Health Plan.

Generally, during a disaster or emergency, Aspire Health Plan will allow you to obtain medical care from out-of-network providers at in-network cost-sharing rates without prior authorization requirements. In cases where payment is required up front for the out-of-network care you may submit a request for reimbursement to the plan.

Aspire Health Plan has a national network of pharmacies available to fill prescriptions for medications. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. In cases where payment for the cost of the drugs is required at the time the prescription is filled you may submit a request for reimbursement to the plan.

  • Claim Reimbursement Request Form (PDF):  English   |   Español

Choose to Share Your Health Information

We are committed to ensuring your health information is safe, while giving you the flexibility to have a family member, friend or loved one – your “representative” – help make decisions on your behalf. State and federal law requires different forms to be used depending on the actions you want your representative to take on your behalf. We’ve outlined the purpose of each of these forms below.

Authorization for Use or Disclosure of Health Information.

Completing the Authorization for Use or Disclosure of Health Information form will allow your designated representative to call Member Services to ask medical questions. This form is valid for as long as you are an Aspire Health Plan member.

USE FOR: Medical benefit questions, claims, and bills.

Authorization for Use or Disclosure of Health Information (PDF):   English  |  Español

  • This form doesn’t override a Power of Attorney (POA). Don’t complete this form if you have a valid POA.

  • You need to complete a separate form, if you need help filing an initial request for coverage, a grievance or appeal.

  • This form is valid as long as you are a health plan member

  • You have the right to revoke this document at any time

Appointment of Representative form .

Completing the Appointment of Representative allows your designated representative to call our Pharmacy Benefits Manager, MedImpact, to ask questions about your Part D prescription drug benefits, claims, or bills. For your Part C benefits, the form also allows the authorized representative to file an appeal or grievance for you, or make an initial coverage request. You will need to renew this form each year.

USE FOR: Part C appeals, grievances, and coverage decisions, as well as Part D prescription drug benefits, claims, bills, appeals, or grievances.

Appointment of Representative Information Form Instructions (PDF):   English  |  Español

Appointment of Representative Information Form (PDF):  English  |  Español

  • This form only allows your representative to assist you with initial coverage requests, grievances or appeals.

  • Your doctor can make a coverage request and file certain appeals without being your representative.

  • This form is only valid for one year.

  • The form should be signed by both you and the individual you would like to represent you.

  • Once you have completed the form, you must submit that form via fax for mail to the applicable fax number or address listed above before we can talk to your representative.

  • You have the right to revoke this document at any time

Already have a  Power of Attorney  (POA)? Make sure it’s Valid

A valid POA must:

  • Name your agent and your relationship to the agent

  • State when it becomes effective (e.g., “immediate”)  and  how long it lasts

  • Include the right to revoke at any time

  • Be properly signed AND notarized or witnessed

Mail-Order Prescriptions

If you rely on regular or long-term medications, there may be a better way to get your prescriptions filled. Birdi Rx is home delivery and a smart, simple way for you to get prescriptions delivered to your door.

  • Home Delivery Registration Form (PDF):  English   |   Español

Give Us a Call

Prospective Members

Toll-free: (866) 798-1530 (TTY 711)

Current Members

Toll-free: (855) 570-1600 (TTY 711)

Local: (831) 574-4938 (TTY 711)

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Why Aspire Health?

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Authorization Request Form (PDF):  English   |   Español

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Notice of Availability

Aspire Health is a Medicare Advantage HMO plan sponsor with a Medicare contract. Enrollment in Aspire Health depends on contract renewal.

Medicare beneficiaries may also enroll in Aspire Health through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov . Every year, Medicare evaluates plans based on a 5-star rating system. For accommodation of persons with special needs at meetings call 1-855-570-1600 (TTY: 711) Other Providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Aspire Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1- 877-486-2048 ), 24 hours a day/7 days a week or consult www.medicare.gov .

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© Copyright 2026 – Aspire Health – All rights reserved. H8764_WEB

Page last updated: May 13, 2026

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