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.

SMALL GROUP FORMS

Affidavit of Extended Dependent Eligibility

Appointment of Representative (Group Members)

Employee Status Change Form

Member Disclosure Form 

Waiver of Coverage

Employer Risk Questionnaire

Employee Enrollment Form

Medical Transition of Care

Continuation of Coverage (Mini-Cobra)

Common Ownership Form

COBRA form

Contractor Relationship - 1099 Affidavit

PEO Questionnaire Form

Small Group Submission Deadline Calendar

Small Group Case Submissions Checklist

Small Group Master Application

Small Group Underwriting Guidelines

LARGE GROUP FORMS

Affidavit of Extended Dependent Eligibility

Appointment of Representative (Group Members)

Employee Status Change Form

Employee Enrollment Form

Member Disclosure Form

Pharmacy Transition of Medications

Waiver of Coverage

Employer Risk Questionnaire

Medical Transition of Care

COBRA form

Large Group Submissions Checklist

Large Group Commission Rate Agreement Form

Large Group Underwriting Guidelines