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Member Materials and Forms | Ambetter from Arkansas 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!
Member Handbooks
- 2020 Member Handbook for Members in the Health Insurance Marketplace (PDF)
- 2020 Member Handbook for Arkansas Works Members (PDF)
Reference Materials
- Auto Bill Pay Terms and Conditions (PDF)
- Dr. Office Visit Checklist (PDF)
- Find a Provider Guide (PDF)
- Get Your Flu Shot
- Health Sheets Education Resource
- Preventive Services Guide (PDF)
- Primary Care Physician Visit Checklist (PDF)
- Quality Improvement (QI) Program
- Statement of Non-Discrimination
- 2020 Transparency Notice
- 2019 Transparency Notice
- Where To Go For Care
- Women's Health and Cancer Rights Act Annual Notice
Forms
- Authorization to Disclose Health Information Form (PDF)
- Grievance, Appeal, Concern or Recommendation Form (PDF)
- Member Reimbursement Medical Claim Form (PDF) - Used to submit a paid claim for Out of Country emergency services received from an out-of-network international provider.
- Prescription Claim Reimbursement Form (PDF)
- Revocation of Authorization to Disclose Health Information (PDF)
- Donor Travel Reimbursement Form (PDF)
- Recipient Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)
- Authorization Representative Designation Form (PDF)