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.

Individuals and Families

• Appointment of Representative
• Designated Record Set (DRS) Request
• Member Disclosure Form
• Medical Direct Member Reimbursement Form
• Medication Exception Request Form
• Pharmacy Reimbursement Form - AvMed pharmacy reimbursements are processed by CVS Caremark.
• Optum Mental Health Direct Reimbursement Form
• Rx - Mail Order Form
• Rx - Mail Order Form - Spanish