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Frequently Used Forms

The files below are in PDF format (icon)


Consent Forms

Hysterectomy Consent & Patient Form
Member Consent Form
Member Education Form
Sterilization Form

Credentialing / Contracting

Health Delivery Organization (HDO) Form – Facilities
Washington Practitioner Application (WPA) Form
Release of Information
CMS Ownership Form


Opioid Policy

Opioid Policy
Opioid Attestation
Opioid Pharmacy Factsheet
Opioid Pharmacy Factsheet 11.22.17
Opioid Prescribers Factsheet
Opioid Webinar Questions


Other

Provider Dispute Request Form
Application for Health Care Coverage
Authorization For the Use and Disclosure of Protected Health Information
Dismissal Letter
Exception to Rule Form
FIS Provider Net Registration Instructions
PCP Change Request Form
PCP Change Request Form - Spanish


Prior Authorization Request Forms

ABA Level of Support Requirement Form
ABA General Information Auth Form
Behavioral Health Prior Auth Request Form 2018
Prior Auth - Pharmacy
Prior Auth - General Specialty Medication Form
Prior Auth – Pre Service Guide Medicaid Effective 01/01/2018
Prior Auth - Pre Service Guide and Request Form Medicaid 01/01/2017
Bariatric Surgery Criteria Pre-Surgical Assessment​
Synagis Authorization Form
Inpatient Rehab, Skilled Nursing Facility, and Long Term Acute Care Request Form Effective 2/1/2018



Provider Changes

PCP & Specialist Termination Notification Form
Service Location Change Form
Provider Information Change Form


Reference / Criteria Guide

BH Provider Prior Authorization Reference Guide FIMC​
BMI Index-for-Age Percentile Charts for Children


Referral Forms

Referral Form for Care Management Services
Weight Watchers Referral Form
Pregnancy Referral Form
 
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