Air Methods Company Air Medical Newsroom Careers Patient & Family Center FORMS LIBRARY APPEAL AUTHORIZATION FORMS As your Advocate, we’d like to assist in the appeal process by submitting an appeal to your insurance. An insurance company may require a signed Designation of Authorized Representative (DOR) Form to be included with the appeal. This form allows Air Methods to represent the patient or policy holder in the appeal process. Please contact our patient advocates at 855-896-9067 to determine which form is required for your insurance. Blue Cross Blue Shield Association Forms Miscellaneous Insurance Forms GENERIC FORMS A100 – Air Methods Generic Appeal Authorization Form ViewDownload This form is used when an insurance company requires a signed authorization by the patient or policy holder, but the insurance company does not have a publicly available form to use. OTHER FORMS LIBRARY A101 – Insurance Questionnaire ViewDownload This form is used to provide Air Methods with insurance coverage information. A102 – Assignment of Benefits Form ViewDownload This form is used to bill, appeal and act as your representative to secure payment from your insurance. A103 – Financial Assistance Application ViewDownload This form is used to apply for financial assistance beyond what has been offered by our patient financial counselors. Financial documentation will be requested. A104 – Member Underpayment Letter ViewDownload This is Air Methods’ generic letter that a patient can use to appeal their insurance’s claim decision. FORMS CONTACT INFORMATION Hours M-F: 8am – 4:30pm (PST) Phone 877-800-5668 Email PBSmedia@airmethods.com Address ATTN: Medical Records P.O. Box 2532 Fontana, CA 92334-9939 ContactMedia CenterSupplier PortalAlert LineFlightDeck Notice of HIPAA Privacy PracticesTerms & Conditions Copyright © 2006-2021 Air Methods. All rights reserved. By clicking “Accept”, you agree to our Terms and Conditions, HIPAA Privacy Practices and Privacy Policy. ACCEPT