The following forms and resources are available to you to view or download.

Application for Enrollment - This link is a copy of the enrollment form and instructions for its completion.

Appointment of Representative Form - You may name a relative, friend, advocate, doctor, or anyone else to act as your Appointed Representative. Other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date this statement giving the person legal permission to be your Appointed Representative.

Benefit Highlights - For an overview of the benefits available to members of DaVita VillageHealth.

Evidence of Coverage [pending approval] - The Evidence of Coverage provides detailed information on covered benefits, cost sharing amounts, how to file a complaint or grievance, and many other important aspects of your DaVita VillageHealth plan.

Summary of Benefits [pending approval] - The Summary of Benefits provides a brief description of the benefits offered by DaVita VillageHealth. The content is provided in a standard format to allow you to easily compare the benefits with other Medicare Advantage plans.

Formulary - A formulary is a list of drugs covered by the DaVita VillageHealth Plan consisting of Generic, Preferred Brand, Brand name, and Specialty drugs.

Provider Directory - This directory includes a list of all the physicians, specialists and hospitals who contract with DaVita VillageHealth.

Pharmacy Directory - This directory includes a nation-wide list of those pharmacies who participate with DaVita VillageHealth.

Home Delivery (Mail Order Pharmacy) - This brochure and reply card provide you with details on the Mail Order Pharmacy benefit and the ability to sign up for the program.

Medicare Prescription Drug Determination Request - This form is utilized to request a determination in writing. It may be completed by you, your physician or your authorized representative if you have problems getting the prescription drugs you believe we should provide. Additional documentation may be required from your physician if you or your authorized representative complete the form. An expedited review or exception may only be requested by a physician. This download includes the instructions for completing the form.

Request for Reconsideration of Medicare Prescription Drug Denial - This form is used when you have received an Adverse Redetermination Notice and you want DaVita VillageHealth to consider your request again.

Submitting Claims - To submit a claim to DaVita VillageHealth for services from out-of-network providers or for which you have already made payment, simply send us a letter with your name, address, and member identification number from your ID Card and attach a copy of the statement you received from the provider or pharmacy and evidence of payment. We will contact you if more information is required.