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Handbooks and Forms for Members | Ambetter from Peach State Health Plan
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!
Quick Reference Guide (QRG)
- 2023 Quick Reference Guide (QRG) Ambetter Bronze, Silver, and Gold Plans (PDF)
- 2023 Quick Reference Guide (QRG) Virtual (PDF)
- 2023 Quick Reference Guide (QRG) Select (PDF)
- 2022 Quick Reference Guide (QRG) Essential, Balanced & Secure Care (PDF)
- 2022 Quick Reference Guide (QRG) Off-Exchange (PDF)
- 2022 Quick Reference Guide (QRG) Select (PDF)
Reference Materials
- Get Your Flu Shot
- Dr. Office Visit Checklist (PDF)
- Preventive Services Guide (PDF)
- Quality Improvement (QI) Program
- Referral and Authorization Information
- Statement of Non-Discrimination
- Balance Billing Disclosures
- 2023 Transparency Notice
- 2022 Transparency Notice
- Where To Go For Care
- Women's Health and Cancer Rights Act Annual Notice
- HB 789 Surprise Bill Transparency Act Information (PDF)
- Ambetter In-Network Hemophilia Pharmacies
- Interoperability and Patient Access
- COVID-19 Home Testing Kits
- Cost Comparison Tool
Forms
- Authorization to Disclose Health Information Form - English (PDF)
- Authorization to Disclose Health Information Form - Chinese (PDF)
- Authorization to Disclose Health Information Form - Vietnamese (PDF)
- Revocation of Authorization Form (PDF)
- Grievance and Appeals Form - English (PDF)
- Grievance and Appeals Form - Chinese (PDF)
- Grievance and Appeals Form - Vietnamese (PDF)
- Authorized Representative Designation Form (PDF)
- Member Reimbursement Medical Claim Form - English (PDF)
- Member Reimbursement Medical Claim Form - Chinese (PDF)
- Member Reimbursement Medical Claim Form - Vietnamese (PDF)
- Member Reimbursement Form - OTC Covid Test (PDF)
- Prescription Claim Reimbursement Form - English (PDF)
- Prescription Claim Reimbursement Form - Chinese (PDF)
- Prescription Claim Reimbursement Form - Vietnamese (PDF)
- Donor Transplant Travel Reimbursement Form - English (PDF)
- Donor Transplant Travel Reimbursement Form - Chinese (PDF)
- Donor Transplant Travel Reimbursement Form - Vietnamese (PDF)
- Recipient Transplant Travel Reimbursement Form - English (PDF)
- Recipient Transplant Travel Reimbursement Form - Chinese (PDF)
- Recipient Transplant Travel Reimbursement Form - Vietnamese (PDF)
- Member Transplant Travel Reimbursement Policy (PDF)