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 (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 Medicare Preferred HMO Enrollment Form - Print and mail this form to AvMed to enroll in AvMed Medicare Preferred HMO.
• 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".