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

Medical Benefit Drugs Requiring Prior Authorization

Medical Drug Authorization Request Form

Medication Exception Request Form

Member Disclosure Form

Pharmacy Drug Authorization Request Form

Pharmacy Drug Mail Order Form (English)

Pharmacy Drug Mail Order Form (Spanish)

Pharmacy Member Reimbursement Form (English)

Pharmacy Member Reimbursement Form (Spanish)