Pharmacy forms

• Coverage Determination (exception) Request Form (PDF)
• Medicare Prescription Payment Plan Election Request Form (PDF)
• Over-the-counter (OTC) catalog and order form (PDF)
• Personal Medication List (PDF)
• Prescription Claim Form (PDF)
• Recommended To-Do List (PDF)
• Request for Redetermination of Medicare Prescription Drug Denial (Online)
• Request for Redetermination of Medicare Prescription Drug Denial (PDF)

Other forms

• Appointment of Representative (AOR) (PDF)
  Use this form to appoint a representative to act on your behalf regarding your appeal request.
  Appointment of Representative Form instructions
• Authorization for Sharing of Health Information (PDF)
  Use this form to give us permission to discuss or disclose your protected health information (PHI) to the individual or organization that you have named on the form.
  • Spanish Authorization for Sharing of Health Information (PDF)
• Disenrollment Form (PDF)
• Attestation of Disenrollment Form (PDF)
• Health Care Privacy Complaint Form (PDF)
  Use this form to file a complaint regarding the AmeriHealth Caritas VIP Care (HMO-SNP) privacy policies, procedures, and practices or compliance with our Notice of Privacy Practices or state and federal privacy rules and laws.
• Personal Representative Request Form (PDF)
  Use this form to provide us information about your personal representative.  This form must include supporting legal documentation.
• Request for Alternate Means of Confidential Communications (PDF)
  Use this form so that communications of your protected health information (PHI) are carried out by alternative means or at an alternate location.
• Request to Amend Protected Health Information (PDF)
  Use this form to request an amendment of your protected health information (PHI) in records that we, or our business associates, maintain in designated record sets.
• Request for List of Disclosures of Protected Health Information (PDF)
  Use this form to request an Accounting of Disclosures of your protected health information (PHI).
• Request to Restrict the Use and/or Disclosure of Protected Health Information (PDF)
  Use this form to ask us to restrict the use and/or disclosure of your protected health information (PHI).
• Revocation of Alternate Means of Confidential Communications (PDF)
  Use this form to revoke a confidential communications request previously given.