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

Magellan Mental Health Direct Member Reimbursement Form - Use this form for services received on or before 12/31/2020

Optum Mental Health Direct Reimbursement Form - Use this form for services received on or after 01/01/2021

Rx - Mail Order Form

Rx - Mail Order Form - Spanish