If you would like to authorize someone else to call HNE and discuss your personal health information, please complete and mail form to the address below. (Please note: the authorization is valid only if signed.)

HNE Medicare Advantage Plan
Enrollment Department
One Monarch Place
Springfield, MA 01144-1500

You may also use the CMS Appointment of Representative Form to appoint someone to represent you in requesting an initial organization or coverage determination or in filing a grievance or appeal. Mail completed forms to the above address.

You may revoke an authorization or end an appointment at any time by sending us a letter to the same address. Please include your name, address, member identification number and a telephone number where we can reach you.

Authorization of Personal Representative Form
Click here for detailed instructions.

HNE offers some additional benefits including our allowance programs. As a member you are eligible to be reimbursed:

• $150 per calendar year for joining a fitness club or Weight Watchers® or for certain over-the-counter items.
• $150 per calendar year for any Dental Services with any dental provider
• $100 every two calendar years for prescription eye wear
• $350 per year for a wig if you are on or recently undergone chemotherapy

Review the brochure attached to the form (see link above) for more details on these and other additional beneftis.

Please send the form with receipts to the address below.

HNE Medicare Advantage Plan
Claims Department
One Monarch Place
Springfield, MA 01144-1500

Additional Benefits – Allowance Programs Reimbursement Form

If you would like to pay your monthly premium as an EFT withdrawal from your checking or savings account, please print, complete, and mail or fax this form to HNE Medicare Advantage.

HNE Medicare Advantage Plan
Accounting Department
One Monarch Place
Springfield, MA 01144-1500
Fax #: 413.233.2730

Forms of payment include:

• Check
• Money Order
• EFT/ACH (automatic withdrawal from checking or savings account)
• Automatic withdrawal from Social Security

Members should make checks or money orders payable to Health New England and mail to:

Health New England Inc.
PO Box 415425
Boston, MA 02241-5425

Electronic Funds Transfer (EFT) Authorization Form

Mail Order is a convenient and cost-effective way for you to order a 90-day supply of medication for delivery to your home, office or location of your choosing. You will minimize trips to the pharmacy and save money on your prescriptions.

Mail Order Forms and Information