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    • Why AvMed?
    • Your AvMed Plan
      • JHS 2021 Plans
      • JHS 2020 Plans
    • Tools and Resources
      • Virtual Visits
      • SmartShopper™
      • 2021 Provider Directory - Jackson First Network
      • 2021 Provider Directory - Select
      • Forms
      • Pregnancy Resources (Healthy Expectations)
      • Talk to a Nurse
      • Condition Self-Management
      • Transplant Case Management
      • Case Management
      • Skilled Nursing Facility/Acute Rehab Transition
      • Prevention and Education
      • Preferred Medication Lists
      • Publications
      • Healthgrades
      • Cost Calculator
      • Embrace Better Health
    • Events Calendar
    • My Account
    • AvMed/
    • Jackson Health System/
    • Tools and Resources/
    • Forms/
    • Virtual Visits
    • SmartShopper™
    • 2021 Provider Directory - Jackson First Network
    • 2021 Provider Directory - Select
    • Forms
    • Pregnancy Resources (Healthy Expectations)
    • Talk to a Nurse
    • Condition Self-Management
    • Transplant Case Management
    • Case Management
    • Skilled Nursing Facility/Acute Rehab Transition
    • Prevention and Education
    • Preferred Medication Lists
    • Publications
    • Healthgrades
    • Cost Calculator
    • Embrace Better Health

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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.


    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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