EMPLOYER 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 Master Application
• Appointment of Representative
• COBRA Application Form
• DRS Request
• Employee Status Change
• Group Employee Enrollment Form
• HIPAA Business Associate Certification Form
• HIPAA Employer Certification Form
• Medical Direct Member Reimbursement Form
• Member Disclosure Form
• Optum Mental Health Direct Reimbursement Form
• Small Group Case Submissions Checklist
• Small Group Submission Deadline Calendar
• Waiver of Coverage Form

EMPLOYER PHARMACY FORMS

• AvMed's Authorization Requirements and Processes
• Medication Exception Request Form
• Member Transition of Service Form – Medical and Pharmacy
• Pharmacy Member Reimbursement Form (English)
• Pharmacy Member Reimbursement Form (Spanish)