Forms

Library

Appeal Authorization Forms

As your Advocate, we’d like to assist in the appeal process by submitting an appeal to your insurance. An insurance company may require a signed Designation of Authorized Representative (DOR) Form to be included with the appeal. This form allows Air Methods to represent the patient or policy holder in the appeal process. Please contact our patient advocates at 855-896-9067 to determine which form is required for your insurance.

Blue Cross Blue Shield Association Forms

Miscellaneous Insurance Forms

Generic Forms

A100 – Air Methods Generic Appeal Authorization Form

a100-air-methods-generic-appeal-authorization-form Download

This form is used when an insurance company requires a signed authorization by the patient or policy holder, but the insurance company does not have a publicly available form to use.

Other Forms Library

A101 – Insurance Questionnaire

a101-insurance-questionnaire Download

This form is used to provide Air Methods with insurance coverage information.

A102 – Assignment of Benefits Form

a102-assignment-of-benefits-form Download

This form is used to bill, appeal and act as your representative to secure payment from your insurance.

A103 – Financial Assistance Application

a103-financial-assistance-application Download

This form is used to apply for financial assistance beyond what has been offered by our patient financial counselors. Financial documentation will be requested.

A104 – Member Underpayment Letter

a104-member-underpayment-letter Download

This is Air Methods’ generic letter that a patient can use to appeal their insurance’s claim decision.

Forms Contact Information

Hours

M-F: 8am – 4:30pm (PST)

Phone

877-800-5668

Email

Address

ATTN: Medical Records
P.O. Box 231480
Las Vegas, NV 89105

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Forms

Library

Appeal Authorization Forms

B100 – Anthem Designation of an Authorization Representative Form

B101 – Anthem Member Authorization Form

B102 – Blue Advantage of Arkansas-Tyson Employees Designation of Authorized Appeal Representative Form

B103 – Blue Advantage of Arkansas-Walmart Employees Designation of Authorized Appeal Representative Form

B104 – Blue Cross Blue Shield FEP Designation of Representative As Authorized Representative For The Disputed Claims Process

B105 – Blue Cross Blue Shield of AL Authorized Representative Form

B106 – Blue Cross Blue Shield of KS Claim Appeal Representative Authorization Form

B107 – Blue Cross Blue Shield of MA Member’s Designation of an Authorized Representative Form

B108 – Blue Cross Blue Shield of MI Designation of Authorized Representative for Appeal Form

B109 – Blue Cross Blue Shield of NC Member Appeal Representation Authorization Form

B110 – Blue Cross Blue Shield of NM Provider Request for Appeal on Behalf of Member Form

B111 – Blue Cross Blue Shield of SC Designation of Authorized Representative to Appeal Form

B112 – Blue Cross of CA Anthem Member Authorization Form

B113 – Blue Cross of ID Authorized Representative Form

B114 – Capital Blue Cross Authorization of Designated Appeals Representative (ADAR) Form

B115 – CareFirst Blue Cross Blue Shield Personal Representative Form

B116 – Empire Blue Cross Blue Shield Member Authorization Form – Downstate

B117 – Florida Blue Member Appeals Appointment of Representative Form

B118 – Highmark Blue Cross Blue Shield Designation of Authorized Representative Form

B119 – Anthem Designation of Representative Authorization Form

M100 – Baptist Health Plan Authorization for Use and Disclosure Form

M101 – Blue Grass Family Health IRE Authorization for the Use and Disclosure of PHI Form

M102 – CDPHP Physician-Provider Designation Form

M103 – Midwest Operating Engineers Welfare Fund Personal Representative Form

M104 – MVP Health Care Member Approval for Appeal Delegation Form

M105 – New Jersey Division of Insurance Consent of Representation in Appeals Form

M106 – Oxford Health Plan Member Appeal Authorization Form

M107 – Texas Department of Insurance Request for Review by an IRO Form

M108 – United Healthcare Designation of Authorized Representative Form

M109 – Aetna Authorized Representative Request Form

M110 – Aetna Accident Plan Benefits Request Form