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 Forms

Direct Deposit Authorization Form

IRS W-9

Application for Agent Appointment

Commercial Group Agent Agreement

HIPAA Plan Sponsor Certification Form

HIPAA Business Associate Certification Form

Small Group Forms

Affidavit of Extended Dependent Eligibility

Appointment of Representative (Group members)

Employee Status Change Form

Member Disclosure Form

Pharmacy Transition of Medications

Waiver of Coverage

Employer Risk Questionnaire

Medical Transition of Care

HIPAA Plan Sponsor Certification Form

Continuation of Coverage (mini-cobra)

Common Ownership Form

COBRA form

Contractor Relationship - 1099 Affidavit

PEO Questionnaire Form

Small Group Employee Enrollment Form

Small Group Submission Deadline Calendar

Small Group Underwriting Guidelines (Effective 1/1/17)

Small Group Underwriting Guidelines (Effective 1/1/18)

Small Group Case Submissions Checklist

2017 Small Group Master Application

2018 Small Group Master Application

Large Group Forms

Affidavit of Extended Dependent Eligibility

Appointment of Representative (Group members)

Employee Status Change Form

Member Disclosure Form

Pharmacy Transition of Medications

Waiver of Coverage

Employer Risk Questionnaire

Medical Transition of Care

HIPAA Plan Sponsor Certification Form

COBRA form

Large Group Submissions Checklist

Large Group Commission Rate Agreement Form

Large Group Employee Enrollment Form

Large Group Underwriting Guidelines