QUICK LINKS

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.

2023 Affidavit of Extended Dependent Eligibility

Appointment of Representative

Authorization to Disclose Protected Health Information (PHI)

Away From Home Form

Coordination of Benefits Update Form

Designated Record Set (DRS) Request

Medical Direct Member Reimbursement Form

Medication Exception Request Form

Member Disclosure Form

Member Transition of Service Form – Medical and Pharmacy

Optum Mental Health Direct Reimbursement Form

Pharmacy Direct Member Reimbursement Form

Rx - Health and Allergy Questionnaire (Commercial)

Rx - Mail Order Form (Commercial)