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
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Direct Member Reimbursement Form (Medimpact) - Pharmacy Claims
- Questions about pharmacy claims or to submit your form email ATRIO Pharmacy at Pharmacy@atriohp.com
- VSP Member 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
- Appeal Request Form - Online | Printable/Fillable PDF
- Grievance Form - Online | Printable/Fillable PDF
Other Forms
- Agent of Record Change Request Form
- Health Risk Assessment (Special Needs Plan)
- Records Request Form