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UPDATED 10/21/20

Documents & Forms

Below you'll find links to important documents and forms for WithMe Health members, providers, and partners. Please send completed forms by fax to 1-866-834-4614 or by mail to:

WithMe Health, ATTN: Member Services
204 E 2nd Ave #337 San Mateo, CA 94401

If you have any issues or questions, please don't hesitate to give us a call at 1-866-840-1877.

  • HIPAA Authorization Form
  • Appointment of Authorized Representative Form
  • Direct Member Reimbursement Form
  • Prior Authorization Request Form
    • Please fax Prior Authorization Forms to 1-866-678-8301

Who We Serve

We're returning control to employers and their members.

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Who We Are

We're personalizing the medication experience.

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Newsroom

Discover what we've done to better medication benefits.

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