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Member Handbooks and Forms | Ambetter from Coordinated Care
Member Resources
Many of our member resources, such as the member handbook and forms, can be found by logging into your online member account. Click Login to create an account and access a wide array of resources!
Ambetter Takes Our Commitment To You Seriously, And Is Honored To Keep You Covered During This Unprecedented Health Situation.
For more details on COVID-19, Ambetter plan coverage, Telehealth, and prescription refills, please visit our FAQs page.
Many of our member resources, such as the member handbook and forms, can be found on our secure portal. Click Login to create an account and access a wide array of resources! We’ve also provided a few resources below.
Quick Reference Guide (QRG)
- 2022 Quick Reference Guide (QRG) Essential, Balanced & Secure Care (PDF)
- 2021 Ambetter Member Handbook (PDF)
- 2020 Ambetter Member Handbook (PDF)
Forms
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - English (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Spanish (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Chinese (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Russian (PDF)
- Authorization to Disclose Health Information Form & Revocation of Authorization Form - Vietnamese (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Member Reimbursement Form - OTC Covid Test (PDF)
- Pharmacy Program Forms
- Prescription Claim Reimbursement Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)
- Member Over The Counter Contraceptive Reimbursement Claim Form (PDF)
- Designated Representative for an Appeal (PDF)
- Grievance and Appeal Form (PDF)
Reference Materials
- Advance Directives
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- Get Your Flu Shot
- Helpful Links
- List of Covered Preventive Services
- Member Rights & Responsibilites (PDF)
- Notice of Privacy - English (PDF)
- Notice of Privacy - Spanish (PDF)
- Notice of Privacy - Chinese (PDF)
- Notice of Privacy - Korean (PDF)
- Notice of Privacy - Russian (PDF)
- Notice of Privacy - Vietnamese (PDF)
- Preventive Services Guide (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- Where To Go For Care
- Women's Health and Cancer Rights Act Annual Notice
- Ambetter In-Network Hemophilia Pharmacies
- Interoperability and Patient Access
- Surprise Medical Bills and Balance Billing
- COVID-19 Home Testing Kits
- Grievance and Appeal Process (PDF)
Complete this Confidentiality Request form (PDF) or the form on the Office of the Insurance Commissioner (OIC) website to request we communicate with you about your health information or other confidential information in different formats and/or to different locations. You may also call, email or make this request on the secure member portal at Ambetter.CoordinatedCareHealth.com.