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
• Fitness Benefit Information and Reimbursement Form

Authorization Forms

• Protected Health Information Disclosure Form
• Protected Health Information Disclosure Form - Spanish
• 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)
• Formulario de Nombramiento de Representante - (Formulario de CMS-1696 ) (Para apelaciones, reclamos y solicitud de cobertura)
• How to Complete the Appointment of Representative Form

Appeals & Grievance Forms

• Part C Appeal Request Form (Medical Services & Supplies)
• Part D Appeal Request Form (Request for Redetermination of Prescription Drug Denial)
• Grievance Form

Other Forms

• Agent of Record Change Request Form
• Health Risk Assessment