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Handbooks & Forms for Members | Ambetter of Illinois
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) (PDF)
- 2023 Quick Reference Guide (QRG) Off-Exchange (PDF)
- 2022 Quick Reference Guide (QRG) Essential, Balanced, & Secure Care (PDF)
- 2022 Quick Reference Guide (QRG) Off-Exchange (PDF)
Reference Materials
- Auto Bill Pay Terms and Conditions (PDF)
- Doctor's Office Visit Checklist (PDF) - Use this checklist to get prepared for your next doctor's appointment.
- 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
- Women's Health and Cancer Rights Act Annual Notice
- Ambetter In-Network Hemophilia Pharmacies
- Printable Provider Directory (PDF)
- Interoperability and Patient Access
- Ambetter Authorization Lookup (PDF)
- 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)
- Prescription Claim Reimbursement Form - English (PDF)
- Prescription Claim Reimbursement Form Chinese (PDF)
- Prescription Claim Reimbursement Form Vietnamese (PDF)
- Grievance and Appeals Form - English (PDF)
- Grievance and Appeals Form - Chinese (PDF)
- Grievance and Appeals Form - Vietnamese (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)
- Transplant Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form - English (PDF)
- Recipient Transplant Travel Reimbursement Form - Chinese (PDF)
- Recipient Transplant Travel 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)
- Member Transplant Travel Reimbursement Policy (PDF)
If you need help finding a network provider and/or pharmacy, please call Member Services. You can also use our online searchable directory called Find a Provider to do so. If you would like a provider directory mailed to you, please call Member Services at 1-855-745-5507 (TTY/TDD 1-844-517-3431).