• View My Benefits
• Find a Provider
• Find a Pharmacy
• Member Forms
• Frequently Asked Questions
• Pharmacy Coverage Determinations
• Appeals & Grievances
• Medication Therapy Management Program
• List of Covered Part D Drugs
• Quality & Safety Edits
• Part D Transition Policy
• Electronic Prescribing Program

Member Forms

Listed below are helpful forms, which may be downloaded and printed.

Complete forms should be mailed to:

Windsor Medicare Extra
Attn: Member Services
7100 Commerce Way
Suite 285
Brentwood, TN 37027

Or faxed to:
Member Services – 615-782-7828

Authorization to Release Protected Health Information Form (PDF)

Health Assessment Form (PDF)

Individual Credit Card Form (PDF)

Individual Account Bank Draft Form (PDF)

Pharmacy Coverage Determination Form (PDF)

Working Aged Survey Form (PDF)