Frequently Used Forms

The files below are in PDF format (icon)

Hysterectomy Consent & Patient Form
Member Consent/Appeal Form
Member Education Form
Sterilization Form
Contract Request Form
Add Provider/Mini Application Form
Health Delivery Organization (HDO) Form – Facilities
CMS Ownership Form
W-9

Opioid Policy
Opioid Attestation Form

Provider Bariatric Program Flyer
Provider Early Reversal Permission Form
Provider Critical Incident Referral Form
Provider Dispute Resolution Request Form
Application for Health Care Coverage
Dismissal Letter
Exception to Rule Form
PCP Change Request Form
PCP Change Request Form - Spanish
WISe Notification Form

Pharmacy
Antivirals : HIV – emtricitabine / tenofovir alafenamide (Descovy®)
Antivirals – HIV Combinations Form
Brand Generic Form
Prior Auth - General Specialty Medication Form
Prior Auth - Pharmacy
Synagis Authorization Form
Pre-Service
Behavioral Health Prior Auth Request Form 2020
Applied Behavior Analysis (ABA) Therapy Prior Authorization Form 2020
Applied Behavior Analysis (ABA) Level of Support Requirement
Applied Behavior Analysis (ABA) Provider UM Guide
FAQs for ABA Treatment Prior Authorization
Prior Auth - Pre-Service Guide Medicaid Effective 01/01/2020
Bariatric Surgery Criteria Pre-Surgical Assessment
Inpatient Rehab, Skilled Nursing Facility, and Long Term Acute Care Request Form Effective 2/1/2018
Private Duty Nursing Prior Authorization Request Form
Provider Change Form
Termination Notification Form

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

Case Management Referral Form
Pregnancy Referral Form
 
Amazon Rewards - Program Information
 
 
Provider Forms are still accepted.  Encourage our members to begin using the new Member Attestation forms.
 

 

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