Forms

AvMed makes it easy to manage your account by providing forms and other tools for making requests. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

• Appointment of Representative (Group members)
• Coordination of Benefits Update Form – Update other insurance information and/or accident details.
• Designated Record Set (DRS) Request – The DRS includes Protected Health Information (PHI) that is used in whole or in part, by or for AvMed to make decisions about members.
• Member Disclosure Form – The Member Disclosure Form authorizes AvMed to disclose Protected Health Information (PHI) to specific individuals.
• Medication Exception Request Form
• Pre-Estimate Request Form – Determine benefit and financial responsibility for a specific service or treatment from a specified provider.
• Reimbursement Request – Use this form request reimbursement for covered expenses that you paid out of pocket.
• Rx - Mail Order Form (Commercial) – Form to be filled out by Commercial members for mail order benefits.
• Rx - Health and Allergy Questionnaire (Commercial) – Questionnaire needed by Medco to assist in filling mail order prescriptions.
• Status Change Form – Change your address or Primary Care Physician. *Please note that some employers require that you change your address with them first. Please make sure to notify your employer of any address changes.
• Pharmacy Transition of Medications
• Medical Transition of Care