Important Member Forms and Documents
Find the forms and documents you need to get the most out of your health plan.
Do you have questions or need help with a form? Call Member Services, 24 hours a day, seven days a week, at 1-833-704-1177 (TTY 1-855-534-6730).
Privacy Forms
- Authorization for Sharing Health Information (PDF)
This form is used to share your protected health information (PHI) where your authorization is required by federal and state privacy laws. - Personal Representative Form (PDF)
The Personal Representative Form lists the person who has legal authority to act on your behalf to make health care decisions. - Privacy Complaint Form (PDF)
Use this form to file a complaint regarding AmeriHealth Caritas New Hampshire’s privacy policies, procedures, and practices or compliance with our Notice of Privacy Practices or state and federal privacy rules and laws. - Request for Alternative Means of Confidential Communications Form (PDF)
Use this form so that communications of your protected health information (PHI) are carried out by alternative means or at an alternate location. - Request for List of Disclosures of Protected Health Information Form (PDF)
Use this form to request an Accounting of Disclosures of your protected health information (PHI). - Request to Amend Protected Health Information Form (PDF)
Use this form to request an amendment of your protected health information (PHI) in records that we, or our business associates, maintain in designated record sets. - Revocation of Alternate Means of Confidential Communications Form (PDF)
Use this form to revoke a confidential communications request previously given.