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Member Materials and Forms | Ambetter from NH Healthy Families
Member Resources
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!
Member Handbooks
- 2020 Ambetter Member Handbook for Members in the Health Insurance Marketplace (PDF)
- 2019 Ambetter Member Handbook for Members in the Health Insurance Marketplace (PDF)
Reference Materials
- Find a Provider Guide (PDF)
- Dr. Office Visit Checklist (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
- Find Community Resources
Forms
- Authorization to Disclose Health Information Form (PDF)
- Revocation of Authorization to Disclose Health Information (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)
- Authorized Representative Form (PDF)