Member Handbooks and Forms

View a complete list of your Apple Health Benefits

Handbooks:

• Coordinated Care Benefits Booklet - English | Spanish 
• Apple Health (Medicaid) Member Handbook - English | Spanish | Chinese

Forms:

• Appeal Form for Member Authorized Representative
• Notification of Pregnancy Form - English | Spanish
• Health Risk Screening Form - English | Spanish
• Primary Care Physician (PCP) Change Form - English | Spanish
• Authorization to Disclose Personal Health Information - English | Spanish
• Revocation of Authorization to Disclose Health Information - English | Spanish
• Member Grievance Form
• DME Referral Form

Health Home Services Resources

• Health Home Brochure
• Health Home Member Booklet
• Health Home Enrollment Letter
• Health Home Opt-Out Form
• Health Home Information Sharing Consent Form
• Health Home Adolescent Information-Sharing Consent

Other Resources:

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