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
Affidavit of Domestic Partnership
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
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