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PROVIDER FORMS

AvMed makes it easy to find the information you and your patients' need. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

Behavioral Health
Care Coordination
Claims & CPT Codes
Contracting
Member Related
Pharmacy - Commercial

Drug Authorization

TBD

Medication Exception

Medication Exception Request Form (Commercial)

Medication Exception Request Form (Medicare)

Prior Authorization

CVS Specialty Drug List - January 2021

CVS Specialty Medication Delivery Program Form

CVS Specialty Referral Form

Member Transition of Service Form – Medical and Pharmacy

Specialty Medication Dis-Enrollment Form
Pharmacy - Medicare
Prior Authorization and Hospital Admission Notification

Admission Notification

Hospital Admission Emergent Urgent Direct Admissions Form

Prior Authorization

Continuity of Care Authorization Form - Out of Network Providers

Medical Prior Authorization Request Form

Member Transition of Service Form – Medical and Pharmacy

Resources

No Authorization Required List Of Procedure Codes

Inpatient Discharge Planning Resources

Notice of Medicare Non-Coverage Form

Notice of Medicare Non-Coverage Form (Spanish)
Provider Data & Demographics
Quality Measures - HEDIS & Stars
Specialty Providers

Behavioral Health

PCP-Behavioral Health Coordination Form

Cardiology

NCH Cardiology FAQs

NCH Cardiology Matrix

Oncology

Medical Oncology & Hematology Prior Authorization Matrix

Ophthalmology

EMI Ophthalmology CPT Code List

Radiology

TBD