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)
• Prescription Claim Form (PDF)
• Prescription mail order form (PDF) and brochure with directions (PDF)
• Recommended To-Do List (PDF)
• 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)
• Health Care Privacy Complaint Form (PDF)
  Use this form to file a complaint regarding the AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan) privacy policies, procedures, and practices or compliance with our Notice of Privacy Practices or state and federal privacy rules and laws.
• 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.
• 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.