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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.
Member Handbook
Reference Materials
- Advance Directives
- 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)
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- Get Your Flu Shot
- Helpful Links
- Grievance and Appeal Process (PDF)
- List of Covered Preventive Services
- Member Rights & Responsibilites (PDF)
- Notice of Privacy - English (PDF)
- Notice of Privacy - Spanish (PDF)
- Notice of Privacy - Chinese
- 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
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization Form (PDF)
- Member Grievance and Appeal Form (PDF)
- Member Reimbursement Medical Claim Form (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)
- Authorized Representative Designation (PDF)