Forms
AvMed makes it easy to manage your account by providing forms and other tools for making requests. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.
Appointment Forms
Direct Deposit Authorization Form
IRS W-9
Application for Agent Appointment
Commercial Group Agent Agreement
HIPAA Plan Sponsor Certification Form
HIPAA Business Associate Certification Form
Small Group Forms
Affidavit of Extended Dependent Eligibility
Appointment of Representative (Group members)
Employee Status Change Form
Member Disclosure Form
Pharmacy Transition of Medications
Waiver of Coverage
Employer Risk Questionnaire
Medical Transition of Care
HIPAA Plan Sponsor Certification Form
Continuation of Coverage (mini-cobra)
Common Ownership Form
COBRA form
Contractor Relationship - 1099 Affidavit
PEO Questionnaire Form
Small Group Employee Enrollment Form
Small Group Submission Deadline Calendar
Small Group Underwriting Guidelines
Small Group Case Submissions Checklist
Small Group Master Application
Large Group Forms
Affidavit of Extended Dependent Eligibility
Appointment of Representative (Group members)
Employee Status Change Form
Member Disclosure Form
Pharmacy Transition of Medications
Waiver of Coverage
Employer Risk Questionnaire
Medical Transition of Care
HIPAA Plan Sponsor Certification Form
COBRA form
Large Group Submissions Checklist
Large Group Commission Rate Agreement Form
Large Group Employee Enrollment Form
Large Group Underwriting Guidelines