Medicare Forms

Access Forms for Medicare Members

AvMed makes it easy to manage your coverage and care by providing forms and other tools. Simply print and complete one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

Enrollment/Administrative Forms

AvMed Medicare Pre-Enrollment Checklist

AvMed Medicare Enrollment Form

AvMed Medicare Formulario para Inscripción

Appointment of Representative (Medicare Members)

Designated Record Set (DRS) Request Form

Medicare Complaint Form

Member Disclosure Form

Prescription Forms

Medicare Coverage Determination Request (English)

Medicare Coverage Determination Request (Spanish)

Medicare Part B (Medical) Drug Authorization Request Form 

Medicare Prescription Drug Mail Order Form

Medicare Redetermination Request Form (English)

Medicare Redetermination Request Form (Spanish)

Part D Transition Policy

Reimbursement Forms

Medical Direct Member Reimbursement Form

Medicare Part B Reimbursement Form

Mental Health Direct Member Reimbursement Form

Pharmacy Medicare Part D Reimbursement Form (English)

Pharmacy Medicare Part D Reimbursement 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.

Quality Assurance Drug Management Programs

AvMed provides quality assurance programs to ensure you receive safe and efficient care.

Drug Utilization Review

Medication Therapy Management (MTM)

Personal Medication List

Personal Medication List - Spanish

Coverage Determination

Part D Prior Authorization Criteria

Part D Step Therapy Criteria

Part D Transition Policy