Record Request & Forms Library

E-Mail completed forms to patientforms@airmethods.com

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

B100 - Anthem Designation of an Authorization Representative Form (pdf)

B101 - Anthem Member Authorization Form (pdf)

B102 - Blue Advantage of Arkansas-Tyson Employees Designation of Authorized Appeal Representative Form (pdf)

B103 - Blue Advantage of Arkansas-Walmart Employees Designation of Authorized Appeal Representative Form (pdf)

B104 - Blue Cross Blue Shield FEP Designation of Representative As Authorized Representative For The Disputed Claims Process (pdf)

B105 - Blue Cross Blue Shield of AL Authorized Representative Form (pdf)

B106 - Blue Cross Blue Shield of KS Claim Appeal Representative Authorization Form (pdf)

B107 - Blue Cross Blue Shield of MA Member's Designation of an Authorized Representative Form (pdf)

B108 - Blue Cross Blue Shield of MI Designation of Authorized Representative for Appeal Form (pdf)

B109 - Blue Cross Blue Shield of NC Member Appeal Representation Authorization Form (pdf)

B110 - Blue Cross Blue Shield of NM Provider Request for Appeal on Behalf of Member Form (pdf)

B111 - Blue Cross Blue Shield of SC Designation of Authorized Representative to Appeal Form (pdf)

B112 - Blue Cross of CA Anthem Member Authorization Form (pdf)

B113 - Blue Cross of ID Authorized Representative Form (pdf)

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

B115 - CareFirst Blue Cross Blue Shield Personal Representative Form (pdf)

B116 - Empire Blue Cross Blue Shield Member Authorization Form - Downstate (pdf)

B117 - Florida Blue Member Appeals Appointment of Representative Form (pdf)

B118 - Highmark Blue Cross Blue Shield Designation of Authorized Representative Form (pdf)

B119 - Anthem Designation of Representative Authorization Form (pdf)

Miscellaneous Insurance Forms

M100 - Baptist Health Plan Authorization for Use and Disclosure Form (pdf)

M101 - Blue Grass Family Health IRE Authorization for the Use and Disclosure of PHI Form (pdf)

M102 - CDPHP Physician-Provider Designation Form (pdf)

M103 - Midwest Operating Engineers Welfare Fund Personal Representative Form (pdf)

M104 - MVP Health Care Member Approval for Appeal Delegation Form (pdf)

M105 - New Jersey Division of Insurance Consent of Representation in Appeals Form (pdf)

M106 - Oxford Health Plan Member Appeal Authorization Form (pdf)

M107 - Texas Department of Insurance Request for Review by an IRO Form (pdf)

M108 - United Healthcare Designation of Authorized Representative Form (pdf)

M109 - Aetna Authorized Representative Request Form (pdf)

M110 - Aetna Accident Plan Benefits Request Form (pdf)

GENERIC FORMS

A100 - Air Methods Generic Appeal Authorization Form
This form is used to request a copy of Medical or Billing Records from Air Methods.

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