Pharmacy forms

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
• Attestation of Disenrollment Form (PDF)
• Authorization for Sharing 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.
• Disenrollment Form (PDF)
• Health Care Privacy Complaint Form (PDF)
  Use this form to file a complaint regarding the AmeriHealth Caritas VIP Care (HMO D-SNP) privacy policies, procedures, and practices or compliance with our Notice of Privacy Practices or state and federal privacy rules and laws.
• Member Reimbursement Dental Claim Form (PDF)
  Use this form if you have paid your provider for dental services and need to get reimbursed. Please consult with your dentist to complete this form in its entirety.
• Personal Representative 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 Access and/or Inspect Protected Health Information (PDF)
• 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.
• Request to Access and/or Inspect Protected Health Information (PDF)
  Use this form to request access to or inspection of your protected health information (PHI) in records that we or our business associates maintain in designated record sets.