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.

Affidavit of Extended Dependent Eligibility

Authorization to Disclose Protected Health Information (PHI)

Away From Home Form

Transition of Care Form

Appointment of Representative

Coordination of Benefits Update Form

Designated Record Set (DRS) Request

Member Disclosure Form

Medication Exception Request Form

Medical Direct Member Reimbursement Form

Pharmacy Direct Member Reimbursement Form

Mental Health Direct Member Reimbursement Form

Rx - Mail Order Form (Commercial)

Rx - Health and Allergy Questionnaire (Commercial)

Pharmacy Transition of Medications