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Handbooks & Forms for Members | Ambetter from PA Health & Wellness
Member Resources
Many of our member resources, such as the member handbook and forms, can be found by logging into your online member account. Click Login to create an account and access a wide array of resources!
Ambetter Takes Our Commitment To You Seriously, And Is Honored To Keep You Covered During This Unprecedented Health Situation.
For more details on COVID-19, Ambetter plan coverage, Telehealth, and prescription refills, please visit our FAQs page.
Member Handbook
Reference Materials
- Get Your Flu Shot
- 2021 Transparency Notice
- 2020 Transparency Notice
- Statement of Non-Discrimination
- Preventive Services Guide (PDF)
- Where to go for Care
- Dr. Office Visit Checklist (PDF)
- Women's Health and Cancer Rights Act Annual Notice
- Ambetter In-Network Hemophilia Pharmacies
- Interoperability and Patient Access
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization to Disclose Health Information Form (PDF)
- Grievance & Complaint Form (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)
- PA Insurance Department Complaint Form