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

Get Your Flu Shot
Balance Billing: Out of Network Covered Emergency Services
Auto Bill Pay Terms and Conditions (PDF)
Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
Preventive Services Guide (PDF)
Quality Improvement (QI) Program
Referral and Authorization Information
Statement of Non-Discrimination
Balance Billing Disclosures
2024 Transparency Notice
2023 Transparency Notice
Where To Go For Care
Women's Health and Cancer Rights Act Annual Notice
Helpful Links
Ambetter In-Network Hemophilia Pharmacies
Interoperability and Patient Access
Cost Comparison Tool
Wellness and Health Information

Forms

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 Form (PDF)

Grievance and Appeals Form - English (PDF)
Grievance and Appeals Form - Simplified Chinese (PDF)
Grievance and Appeals Form - Traditional Chinese (PDF)
Grievance and Appeals 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)

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

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 Transplant Travel Reimbursement Policy (PDF)

Handbooks & Forms for Members | Ambetter from Buckeye Health Plan

Member Resources

Quick Reference Guide (QRG)

Reference Materials

Forms

Authorization to Disclose Health Information Form

Revocation of Authorization Form

Grievance and Appeals Form

Member Reimbursement Medical Claim Form

Prescription Claim Reimbursement Form

Donor Transplant Travel Reimbursement Form

Recipient Transplant Travel Reimbursement Form

Member Transplant Travel Reimbursement Policy