Member Forms

In this section you will be able to access important ATRIO forms. For assistance in completing any of these forms, please contact Customer Service and one of our representatives will be happy to assist you.

Reimbursement Forms

• Direct Member Reimbursement Form - Medical Claims Only
• Pharmacy Claim Reimbursement Form
• VSP Member Reimbursement Form

Authorization Forms

• Protected Health Information Disclosure Form
• Appointment of Representative Form (CMS Form -1696) (For Appeals, Grievances, and Coverage Request)
• Appointment of Representative Form (CMS Form -1696) (For Appeals, Grievances, and Coverage Request) (Large Print)
• How to Complete the Appointment of Representative Form

Appeals & Grievance Forms

• Appeal Request Form
• Grievance Form

Other Forms

• Agent of Record Change Request Form
• Records Request Form