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
Brand Generic
General Specialty Medication
Pharmacy Prior Authorization
Synagis Authorization
12.10.99.AB – Antivirals: HIV –Cabotegravir/rilpivirine (Cabenuva)
21.53.40 – TKI Policy
23.10.00 – Testosterone
39.35.00 – PCSK9
45.30.00 – Cystic Fibrosis
52.55.00 – IBS/GI Motility
59.40.00.18 – Vraylar
65.20.00.10 – Buprenorphine
65.20.00.E5 – Sublocade
66.27.00 – Cytokine and CAM 
67.70.10 – CGRP (Acute)
67.70.20 – CGRP (Treatment)
68.00.00 – Gout
 
Pre-Service
Behavioral Health Admission Notification/Authorization Request Form 2021
Applied Behavior Analysis (ABA) Therapy Prior Authorization Form 2021
Applied Behavior Analysis (ABA) Level of Support Requirement
Applied Behavior Analysis (ABA) Provider UM Guide
FAQs for ABA Treatment Prior Authorization
Prior Authorization Pre-Service Guide Medicaid 2021
Bariatric Surgery Criteria Pre-Surgical Assessment
Inpatient Rehab, Skilled Nursing Facility, and Long Term Acute Care Request Form
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

 
Provider Forms
Amazon Rewards – Provider Form: Children and Adolescents
Amazon Rewards – Provider Form: Adults
 
Member Forms
Amazon Rewards – Program Information
Amazon Rewards – 30 Month Well-Child Visits
Amazon Rewards – Childhood Immunizations
Amazon Rewards – 3-11 Year Well-Care Visits
Amazon Rewards – ADHD Medication Follow-Up Visit
Amazon Rewards – Immunizations for Adolescents
Amazon Rewards – 12-21 Year Well-Care Visits
Amazon Rewards – Chlamydia Screening
Amazon Rewards – Prenatal Visit
Amazon Rewards – Postpartum Visit 
Amazon Rewards – Breast Cancer Screening
Amazon Rewards – Cervical Cancer Screening
Amazon Rewards – Diabetes Screening
Amazon Rewards – Adolescent & Adult Combined Form

  

Amazon Rewards – Program Information (Spanish)
Amazon Rewards – 30 Month Well-Child Visits (Spanish)
Amazon Rewards – Childhood Immunizations (Spanish)
Amazon Rewards – 3-11 Year Well-Care Visits (Spanish)
Amazon Rewards – ADHD Medication Follow-Up Visit (Spanish)
Amazon Rewards – Immunizations for Adolescents (Spanish)
Amazon Rewards – 12-21 Year Well-Care Visits (Spanish)
Amazon Rewards – Chlamydia Screening (Spanish)
Amazon Rewards – Prenatal Visit (Spanish)
Amazon Rewards – Postpartum Visit (Spanish)
Amazon Rewards – Breast Cancer Screening (Spanish)
Amazon Rewards – Cervical Cancer Screening (Spanish)
Amazon Rewards – Diabetes Screening (Spanish)
Amazon Rewards – Adolescent & Adult Combined Form (Spanish)
 

 

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