Member Resources

Many of our member resources 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)

2025 Quick Reference Guide (QRG) - Web Version
2025 Quick Reference Guide (QRG) (PDF)
2024 Quick Reference Guide (QRG) (PDF)
2024 Quick Reference Guide (QRG) Off-Exchange (PDF)
2024 Quick Reference Guide (QRG) Select (PDF)

Reference Materials

Get Your Flu Shot
Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
Statement of Non-Discrimination
Balance Billing Disclosures
2024 Transparency Notice
2023 Transparency Notice
Preventive Services Guide (PDF)
Where to go for Care
Women's Health and Cancer Rights Act Annual Notice
Member Appeals
Balance Billing
Ambetter In-Network Hemophilia Pharmacies
Interoperability and Patient Access
Cost Comparison Tool
Wellness and Health Information

Forms

Authorization to Disclose Health Information Form - English (PDF)
Authorization to Disclose Health Information Form - Simplified Chinese (PDF)
Authorization to Disclose Health Information Form - Traditional Chinese (PDF)
Authorization to Disclose Health Information Form - Vietnamese (PDF)

Revocation of Authorization Form (PDF)

Member Reimbursement Medical Claim Form - English (PDF)
Member Reimbursement Medical Claim Form - Simplified Chinese (PDF)
Member Reimbursement Medical Claim Form - Traditional Chinese (PDF)
Member Reimbursement Medical Claim Form - Vietnamese (PDF)

Continuity of Care Assistance Form - English (PDF)
Continuity of Care Assistance Form - Spanish (PDF)

Coordination of Care Form (PDF)

Prescription Claim Reimbursement Form - English (PDF)
Prescription Claim Reimbursement Form - Simplified Chinese (PDF)
Prescription Claim Reimbursement Form - Traditional Chinese (PDF)
Prescription Claim Reimbursement Form - Vietnamese (PDF)

Member Grievance Request Form (PDF)

Appointment of Representative Form (PDF)

Donor Transplant Travel Reimbursement Form - English (PDF)
Donor Transplant Travel Reimbursement Form - Simplified Chinese (PDF)
Donor Transplant Travel Reimbursement Form - Traditional Chinese (PDF)
Donor Transplant Travel Reimbursement Form - Vietnamese (PDF)

Recipient Transplant Travel Reimbursement Form - English (PDF)
Recipient Transplant Travel Reimbursement Form - Simplified Chinese (PDF)
Recipient Transplant Travel Reimbursement Form - Traditional Chinese (PDF)
Recipient Transplant Travel Reimbursement Form - Vietnamese (PDF)

Member Transplant Travel Reimbursement Policy (PDF)

Health Care Appeal Request Form - English (PDF)
Health Care Appeal Request Form - Simplified Chinese (PDF)
Health Care Appeal Request Form - Traditional Chinese (PDF)
Health Care Appeal Request Form - Vietnamese (PDF)

Ambetter Handbooks & Forms | Ambetter from Arizona Complete Health

Member Resources

Quick Reference Guide (QRG)

Reference Materials

Forms

Authorization to Disclose Health Information Form

Revocation of Authorization Form

Member Reimbursement Medical Claim Form

Continuity of Care Assistance Form

Coordination of Care Form

Prescription Claim Reimbursement Form

Member Grievance Request Form

Appointment of Representative Form

Donor Transplant Travel Reimbursement Form

Recipient Transplant Travel Reimbursement Form

Member Transplant Travel Reimbursement Policy

Health Care Appeal Request Form