Member Handbooks and Forms

• Apple Health (Medicaid) Member Handbook - English
• Apple Health (Medicaid) Member Handbook - Spanish 

• Handbooks for Members in Chelan, Douglas & Grant Counties (North Central Region)
  
  • Behavioral Health Services Only (BHSO) - English 
  • Behavioral Health Services Only (BHSO) - Spanish

• Appeal Form for Member Authorized Representative (PDF)

• Primary Care Physician (PCP) Change Form - English (PDF) 
• Primary Care Physician (PCP) Change Form - Spanish (PDF)

• Authorization to Disclose Personal Health Information - English (PDF) 
• Authorization to Disclose Personal Health Information - Spanish (PDF)

• Revocation of Authorization to Disclose Health Information - English (PDF) 
• Revocation of Authorization to Disclose Health Information - Spanish (PDF)

• Member Grievance Form (PDF)
• DME Referral Form (PDF)
• Prescription Claim Reimbursement Form (PDF)

Health Home is a set of services to assist members with chronic conditions, like diabetes, asthma, heart disease and others. Our care coordinators help you create a plan to improve and support your care. For more information, check out the links below.

• Health Home Brochure - English (PDF) 
• Health Home Brochure - Spanish (PDF)
• Health Home Member Booklet (PDF)
• Health Home Opt-Out Form (PDF)
• Health Home Information Sharing Consent Form (PDF)
• Health Home Adolescent Information-Sharing Consent (PDF)

• Adult Immunization Record (PDF)
• Advance Directives Policy (PDF)
• Tobacco Cessation Program Description (PDF)
• Medically Intensive Children's Program (MICP) flyer - English (PDF) 
• Medically Intensive Children's Program (MICP) flyer - Spanish (PDF)
• Preventive Health and Clinical Practice Guidelines