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

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

Interoperability

Filing a Complaint - How to file a complaint with the Office of Civil Rights or the Federal Trade Commission.

Member FAQs - Information related to the factors enrollees should consider in selecting a health information management application.

Privacy Rights - Strategies enrollees may use to safeguard the privacy and security of their data.