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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.

2024 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

Medical Drug Authorization Request Form

Member Disclosure Form

Member Transition of Service Form – Medical and Pharmacy

Optum Mental Health Direct Reimbursement Form

Pharmacy Drug Authorization Request Form

Pharmacy Drug Mail Order Form (English)

Pharmacy Drug Mail Order Form (Spanish)