Record Request
& 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.

Generic Forms

A100 – Air Methods Generic Appeal Authorization Form

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

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

A102 – Assignment of Benefits Form

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

A103 – Financial Assistance Application

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

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

Records Request Forms

A105 – Authorization to Release Medical Information

This form is used to request a copy of Medical or Billing Records from Air Methods.

Medical Records Contact Information

Hours

M-F: 8am – 4:30pm (PST)

Phone

877-800-5668

Address

ATTN: Medical Records
P.O. Box 2532
Fontana, CA 92334-9939