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Avera Health Plans Provider Supplies Request Form

To request additional supplies from Avera Health Plans, please use the form below or contact Network Services, Monday through Friday, 8 a.m. to 5 p.m., CT at 605-322-4545 or toll free at 1-888-322-2115.

  * Required Fields
Date Requested:
* Provider Name:
* Address Line 1:
Address Line 2:
* City:
* State:
* Zip:
Attention:
* Phone:
Items and Quantities Requested:
 
  Quantity Item
Formulary List
AHP Signage
Provider Directory
Provider Manual
Other