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Handbooks & Forms | Ambetter from MHS Indiana
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!
Ambetter Takes Our Commitment To You Seriously, And Is Honored To Keep You Covered During This Unprecedented Health Situation.
For more details on COVID-19, Ambetter plan coverage, Telehealth, and prescription refills, please visit our FAQs page.
Member Handbook
Reference Materials
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- Get Your Flu Shot
- Preventive Services Guide (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- 2021 Transparency Notice
- 2020 Transparency Notice
- Where To Go For Care
- Women's Health and Cancer Rights Act Annual Notice
- Ambetter In-Network Hemophilia Pharmacies
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization (PDF)
- Grievance and Appeals 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)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)