Soundpath Health Forms & Tools

Soundpath Health Customer Service Representatives are available to assist you Monday through Friday from 8 am - 8 pm. We are also available to answer your questions via email at To reach us by phone, please contact us toll free at 1-866-789-7747 (TTY 711). Our hours of operation are 8 am - 8 pm, Monday through Friday and 8 am - 8 pm, Saturday and Sunday from October 1 to March 1.

& Tools

Reference Information

Rights and Responsibilities Upon Disenrollment View Page
Washington State Advance Directive DOWNLOAD
(By clicking on this link, you will be directed to non-Medicare information.)
2018 Star Ratings Information  DOWNLOAD 
2017 Star Ratings Information DOWNLOAD
Authorization to Disclosure Protected Health Information DOWNLOAD

CMS Appointment of Representative Form

To appoint someone to act on your behalf, please complete this form and return it to the plan.
This link will take you to a new website. 

Notice of Privacy Practices DOWNLOAD
Multi-Language Sheet DOWNLOAD
Member Emergency Information DOWNLOAD

Other Forms

2018 Enrollment Form DOWNLOAD
2018 Plan Change Enrollment Form DOWNLOAD
Scope of Appointment  DOWNLOAD
Premium Payment Form Download
2018 Prescription Drug Reimbursement Request Form DOWNLOAD
2015, 2016, 2017 Prescription Drug Reimbursement Request Form DOWNLOAD
VSP Reimbursement Form DOWNLOAD

Mail Order Forms

2018 Prescription Mail Order Form (Optum Rx) DOWNLOAD
Prescription Mail Order Form (from Walgreens) DOWNLOAD

Medical Referrals & Authorizations

2018 POD1/PSW Part B Prior Authorization Form
2018 Medical Prior Authorization and Notification List
2018 Soundpath Health Medical Prior Authorization Request Form

Pharmacy Authorization Tools

2018 Comprehensive Formulary
2018 Prior Authorization Requirements
2018 Step Therapy Requirements
2018 Pharmacy Part D Coverage Determination Request Form DOWNLOAD
2018 Part D Prescription Tier Cost Sharing Exception Request Form
2018 Hospice Override or Status Change Form
2018 Soundpath Health ONLINE Pharmacy Part D Coverage Determination Requests through Optum Rx 
(Note: This link will direct you to a non-Medicare website)

Claims & Provider Tools

Contracted Providers Appeals Form Download
Non-Contracted Providers Appeals Form Download   
New Provider Remittance Advice Definitions DOWNLOAD
Sample CMS-1500 DOWNLOAD
Waiver Liability Form Download

 Provider change form
 Provider termination form 
 Add New Provider to Current Provider Participation Agreement
 Soundpath Health Provider Manual
 Soundpath Health Claims Process Code Updates
 Soundpath Health Provider Pulse Newsletter

Page Last Updated: January 28, 2019