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

Pharmacy Direct Member Reimbursement Form

Mental Health Direct Member Reimbursement Form

Rx - Mail Order Form

Rx - Mail Order Form - Spanish