Member Resources

Many of our member resources can be found by logging into your online member account. Click Login to create an account and access a wide array of resources!

Quick Reference Guide (QRG)

2024 Quick Reference Guide (QRG)
2024 Quick Reference Guide (QRG) (PDF)
2024 Quick Reference Guide (QRG) Off-Exchange (PDF)
2023 Quick Reference Guide (QRG) (PDF)

Reference Materials

PCP Referrals
Balance Billing Disclosures
2024 Transparency Notice
2023 Transparency Notice
Women's Health and Cancer Rights Act Annual Notice
Ambetter In-Network Hemophilia Pharmacies
Prescription Claim Reimbursement Form (PDF)
Interoperability and Patient Access
Preventive Services Guide (PDF)
Contraceptive Coverage Summary (PDF)
Non-Prescription Contraception Drugs or Devices (PDF)
Cost Comparison Tool
Wellness and Health Information
Mental Health Resources

Forms

Grievance and Appeals Forms (PDF)
Grievance and Appeals Forms - Simplified Chinese (PDF)
Grievance and Appeals Forms - Traditional Chinese (PDF)
Grievance and Appeals Forms - Vietnamese (PDF)

Authorization to Disclose Health Information Form - English (PDF)
Authorization to Disclose Health Information Form - Simplified Chinese (PDF)
Authorization to Disclose Health Information Form - Traditional Chinese (PDF)
Authorization to Disclose Health Information Form - Vietnamese (PDF)

Revocation of Authorization to Disclose Health Information Form (PDF)

Donor Transplant Travel Reimbursement Form - English (PDF)
Donor Transplant Travel Reimbursement Form - Simplified Chinese (PDF)
Donor Transplant Travel Reimbursement Form - Traditional Chinese (PDF)
Donor Transplant Travel Reimbursement Form - Vietnamese (PDF)

Member Reimbursement Medical Claim Form - English (PDF)
Member Reimbursement Medical Claim Form - Simplified Chinese (PDF)
Member Reimbursement Medical Claim Form - Traditional Chinese (PDF)
Member Reimbursement Medical Claim Form - Vietnamese (PDF)

Member Transplant Travel Reimbursement Policy (PDF)

Recipient Transplant Travel Reimbursement Form - English (PDF)
Recipient Transplant Travel Reimbursement Form - Simplified Chinese (PDF)
Recipient Transplant Travel Reimbursement Form - Traditional Chinese (PDF)
Recipient Transplant Travel Reimbursement Form - Vietnamese (PDF)

Member Over The Counter Contraceptive Reimbursement Claim Form (PDF)

Authorized Representative Designation Form (PDF)

Handbooks & Forms | Ambetter from Western Sky Community Care

Member Resources

Quick Reference Guide (QRG)

Reference Materials

Forms

Grievance and Appeals Forms

Authorization to Disclose Health Information Form

Revocation of Authorization to Disclose Health Information Form

Donor Transplant Travel Reimbursement Form

Member Reimbursement Medical Claim Form

Member Transplant Travel Reimbursement Policy

Recipient Transplant Travel Reimbursement Form

Member Over The Counter Contraceptive Reimbursement Claim Form

Authorized Representative Designation Form