Member Forms
Advance Directives
You have a right to make decisions about your medical care. An advance directive is a form you can fill out to protect your rights. It can help your family and your doctor know your wishes about your care. You have a right to accept or refuse treatment. You also have the right to plan and direct the types of health care you may receive in the future.
RxDirect Mail Order Program
CeltiCare offers a 90 day supply (3 month supply) of certain maintenance medications by mail*. Fill out this form and follow the instructions to start receiving your medications by mail!
*Commonwealth Care Type 1 members are not eligible for the RxDirect Mail Order Program.
Notification of Pregnancy
It is important to take prenatal vitamins while you are pregnant. They give extra nutrients to your baby. CeltiCare gives a FREE 90 day supply of prenatal vitamins when you notify us of your pregnancy! Print this form, and have your doctor follow the instructions to submit it to CeltiCare. Your doctor must complete the form and send it back. If you can not print the form, ask your doctor to contact CeltiCare at your next appointment.
Authorized Representative
If you would like to allow a family member or other individual to speak with CeltiCare on your behalf, please print this form and follow the instructions to submit it to CeltiCare.
CentAccount® Health Risk Screening Form
CeltiCare gives you more ways to pay for your healthcare with our CentAccount® program. You can start earning money as soon as you become a member! Print and complete this form and follow the instructions to submit it to CeltiCare today.
If you have questions about any of these forms, please call the CeltiCare Member Services Department,
Monday through Friday, 8AM-5PM, at (866)895-1786.
