Forms

View and print important forms.

Group Members

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.

Group-Specific, Miami-Dade/JHS Only

Affidavit of Support
Affidavit of Eligibility for Dependents 25-30
Authorization to Disclose Protected Health Information (PHI)
Away From Home Form – If you have covered dependents, including students who are away at school or do not live with you on a regular basis, please complete this form to allow them easy access to the PHCS nationwide network.
Request for Reimbursement Form
Transition of Care Form – If you are currently seeing a Beech Street provider who will not be in the 2010 network, and you feel that your condition requires continuing care under your current specialist, you may fill out the Transition of Care form and fax it to AvMed.

Medicare Members

Appointment of Representative (Medicare members) - This form is required if someone other than the AvMed Medicare member is completing an appeal. It gives permission for the appointed person to act on behalf of the AvMed member and allows AvMed to discuss the appeal with the representative.
AvMed Premier Care Enrollment Form - Print and mail this form to AvMed to enroll in AvMed Premier Care HMO.
AvMed Medicare Preferred PPO Enrollment Form - Print and mail this form to AvMed to enroll in AvMed Medicare Preferred PPO.
Designated Record Set (DRS) Request Form - Use this form to ask for a record of a member’s Designated Record Set (DRS). The DRS includes Protected Health Information (PHI) that is used in whole or in part, by or for AvMed to make decisions about members.
Rx - Mail Order Form (Medicare) - Form to be filled out by Medicare members for mail order benefits.
Rx - Health and Allergy Questionnaire (Medicare) - Questionnaire needed by Medco to assist in filling mail order prescriptions.
Medication Exception Request Form - This form is to be completed by physicians requesting an exception to AvMed’s formulary.
Member Disclosure Form - The Member Disclosure Form authorizes AvMed to disclose Protected Health Information (PHI) to specific individuals.
Request for Reimbursement Form - Use this form to request reimbursement for covered expenses that you paid out-of-pocket.
Transition Policy - Use this form to transition "Part D Drugs".