Members can use the forms on this page to request payment, appoint a representative, and more.
- Appeal request form PDF
- Coverage Determination Request Form PDF
- Personal medication list PDF January 18, 2023
- Prescription Claim Form PDF
- Prescription Mail Order Form PDF and brochure with directions PDF
- Recommended To-Do List PDF January 18, 2023
- Request for Redetermination of Medicare Prescription Drug Denial
- Appointment of a Representative PDF
Use this form to appoint a representative to act on your behalf regarding your appeal request.
- Appointment of Representative Form instructions
- Authorization for Disclosure of Health Information PDF
- Notice of Privacy Practices PDF
How medical information about you may be used and disclosed and how you can get access to this information.
- Personal Representative Request Form PDF
This form will be used to confirm a member's permission that AmeriHealth Caritas VIP Care Plus may discuss or PHI to a particular person who acts as the member's personal representative.