Forms available for download
See the list below for various forms you can download. If you need a specific form and don't see it, please call Member Services at 888-623-3195.
Member Grievance, Appeal or Concern Form
This is a form used to file a formal grievance or appeal or to share a concern with Antidote.
Prior Authorization Form
This is a form members or providers submit to Antidote to request approval for specific medications, treatments, or services to ensure they are medically necessary and covered under the member's health plan. For ease and faster delivery, fill out the electronic Prior Authorization.
- Medical
Direct Member Reimbursement Form
This form is used to request reimbursement for payment you made directly to a provider. For 2024 plans, please use this form.
- Pharmacy
Direct Member Reimbursement Form
This form is used to request reimbursement for payment you made on a prescription drug, supply or other item. For 2024 plans, please use this form.
- Pharmacy
Exception to Coverage Form
This form is submitted by a member or provider requesting coverage for a medication or treatment not typically covered under the members' health plan. You can also access this upon login to the Antidote Member Portal and submit electornically.
Authorized Representative Form
This form allows someone to act on your behalf in specific matters, like accessing health information, making decisions, or managing claims. It outlines their permissions, duration of authority, and your consent.
