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    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.




    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

    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

    COBRA form

    Large Group Submissions Checklist

    Large Group Commission Rate Agreement Form

    Large Group Employee Enrollment Form

    Large Group Underwriting Guidelines

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