Forms

Request a Provider Directory, Pharmacy Directory, or Formulary (List of Covered Drugs)

Complete this form to get a Provider Directory, a Pharmacy Directory or a Formulary (List of Covered Drugs) mailed to you.

Pharmacy forms

Enrollment and member change forms

Reimbursement forms for Fallon Senior Plan Flex Enchanced Rx HMO members

Privacy 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 it easy for you to print the appropriate form and submit it according to the directions on the form.

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_2018_24 Pending
The information on this page was last updated on 10/1/2017.

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.)

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