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!

Many of our member resources, such as the member handbook and forms, can be found on our secure portal. Click Login to create an account and access a wide array of resources! We’ve also provided a few resources below.

Quick Reference Guide (QRG)

Forms

Member Over The Counter Contraceptive Reimbursement Claim Form (PDF)

Member Transplant Travel Reimbursement Policy (PDF)

Designated Representative for an Appeal (PDF)

Reference Materials

Complete this Confidentiality Request form (PDF) or the form on the Office of the Insurance Commissioner (OIC) website to request we communicate with you about your health information or other confidential information in different formats and/or to different locations. You may also call, email or make this request on the secure member portal at Ambetter.CoordinatedCareHealth.com.

Member Handbooks and Forms | Ambetter from Coordinated Care

Member Resources

Quick Reference Guide (QRG)

Forms

Authorization to Disclose Health Information Form

Revocation of Authorization Form

Member Reimbursement Medical Claim Form

Member Over The Counter Contraceptive Reimbursement Claim Form

Donor Transplant Travel Reimbursement Form

Recipient Transplant Travel Reimbursement Form

Member Transplant Travel Reimbursement Policy

Grievance Form

Appeal Form

Pharmacy Forms

Designated Representative for an Appeal

Record Request Form

Reference Materials