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.

Individuals and Families

Appointment of Representative

Designated Record Set (DRS) Request

Member Disclosure Form

Medical Direct Member Reimbursement Form

Medication Exception Request Form

Optum Exchange of Information Form

Optum Mental Health Direct Reimbursement Form

PCP-Behavioral Health Communication Form

Pharmacy Member Reimbursement Form - AvMed pharmacy reimbursements are processed by CVS Caremark.

Rx - Mail Order Form

Rx - Mail Order Form - Spanish

Interoperability

Filing a Complaint - How to file a complaint with the Office of Civil Rights or the Federal Trade Commission.

Member FAQs - Information related to the factors enrollees should consider in selecting a health information management application.

Privacy - Strategies enrollees may use to safeguard the privacy and security of their data.