For your convenience, our most frequently requested forms for Medivest members are available here. Download and return these completed forms by email or fax them to 407-971-4742.
Attendant Care Reimbursement Form – Use this form to request reimbursement for expenses you incur from paying your attendant care providers.
Beneficiary Designation Form – Use this form to designate or change the beneficiary of your custodial account. The individual(s) or estate you designate will receive the balance of your custodial account once it closes after your death. You may designate a beneficiary if you have a reversionary interest in your custodial account as specified in your settlement.
HIPAA Patient General Release of Information Form – Medivest requires your release in order to discuss your injury with medical providers, vendors and pharmacies.
Member Reimbursement Form – Use this form to request reimbursement from your custodial account for qualified out-of-pocket medical expenses you have personally incurred related to your injury.