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Member Materials and Forms | Ambetter from Buckeye Health Plan
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!
- Balance Billing: Out of Network Covered Emergency Services
- Auto Bill Pay Terms and Conditions (PDF)
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- Find a Provider Guide (PDF)
- Preventive Services Guide (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- 2020 Transparency Notice
- 2019 Transparency Notice
- Where To Go For Care
- Women's Health and Cancer Rights Act Annual Notice
- Helpful Links
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization Form (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)