Forms

Pharmacy forms

• Coverage Determination (exception) 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 Disclosure of Health Information (PDF)
  The form gives us permission to discuss or disclose your protected health information (PHI) to the individual that you have named on the form. It must be signed by you or your personal representative.
• Spanish Authorization for Disclosure of Health Information (PDF)
• Disenrollment Form (PDF)
• Attestation of Disenrollment Form (PDF)
• Personal Representative Request Form (PDF)
  This form will be used to confirm a member's permission that AmeriHealth Caritas VIP Care may discuss or share PHI to a particular person who acts as the member's personal representative.
• 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).