Forms

Members can use the forms on this page to request payment, appoint a representative, and more.

Pharmacy forms

• 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

Medical forms

• Appeal Request Form PDF
• Prior Authorization Form PDF

Other forms

• 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.