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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!
Quick Reference Guide (QRG)
- 2023 Quick Reference Guide (QRG) (PDF)
- 2022 Quick Reference Guide (QRG) Essential, Balanced & Secure Care (PDF)
- 2022 Quick Reference Guide (QRG) Off-Exchange (PDF)
Reference Materials
- Get Your Flu Shot
- Balance Billing Disclosures
- 2023 Transparency Notice
- 2022 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
- Broker Compensation
- COVID-19 Home Testing Kits
- Cost Comparison Tool
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)
- Member Reimbursement Form - OTC Covid Test (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