Request a Provider Directory or a Pharmacy Directory
Complete this form to get a Provider Directory or a Pharmacy Directory mailed to you.
Enrollment and member change forms
Because Fallon Health is dedicated to protecting your privacy, we are strict about who can see your information. However, there may be times that you want to allow certain other people to see your information or perhaps get a copy for yourself. Fallon makes this easy for you to do by printing off the appropriate form and submitting it according to the directions on the form.
Amendment Request for Personal Information form (pdf)
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.
Personal Representative Authorization Form - Accessing Personal Information (SCO_2010_130 8/20/10, pdf)
Identify a personal representative—someone Fallon can release your personal information to. Complete a form for each person you want to have as a representative.
Personal Representative Authorization Form – Filing an Appeal or Grievance (SCO_2015_158 Approved 04282015, pdf)
This form is to be used by Fallon Senior Plan members to authorize someone to file an appeal or grievance on the member’s behalf. Note: This form automatically expires after a year.
CMS' Appointment of Representative form (pdf, 68 KB)
This form may be used to appoint someone to handle a grievance or coverage determination, or to deal with any level of the appeal process. Return the completed form to Fallon Health, Member Appeals and Grievances, 10 Chestnut St., Worcester, MA 01608.
Veteran’s Office Authorization for Release of Personal Information form (pdf, 47 KB)
Allow a veteran’s office to receive your personal information from Fallon Health.
Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Health’s notice of privacy practices, updated on September 23, 2013.
Request for an Accounting of Disclosures of Personal Information form (pdf, 36 KB)
Request a listing of who Fallon has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.
Restriction form (pdf, 36 KB)
Request a limit on how we use or share your personal information.
Fallon Senior Plan is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Fallon Senior Plan depends on contract renewal. To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Fallon Senior Plan website.)
H9001_F_2017_21 Approved 10172016
The information on this page was last updated on 10/1/2016.
Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)