Forms

Access key forms for authorizations, claims, pharmacy and more.

Authorizations

• DME Authorization Request Form (PDF)
• Hepatitis C Treatment Prior Authorization (PDF)
• Home Health Services Request (PDF)
• Hospice Prior Authorization Request (PDF)
• Inpatient Authorization Request (PDF)
• Notice of Pregnancy Notification (PDF)
• Outpatient Authorization Request (PDF)
• Personal Care Assistant/Medical Day Care Request (PDF)
• Skilled Therapy Services (OT/PT/ST) Prior Authorization (PDF)
• Transplant Authorization Request (PDF)

Behavioral Health

• Behavioral Analysis for Autism Spectrum Disorder (PDF)
• Detox and Substance Abuse Rehab Service Request (PDF)
• Electroconvulsive Therapy Services Request (PDF)
• Inpatient, Sub-acute and CSU Service Request (PDF)
• PHP and IOP Service Request (PDF)
• Psychological and Neuropsychological Service Request (PDF)
• Residential Treatment Service Request (PDF)
• Routine Outpatient Services Request (PDF)

Dental

• Bidirectional Tool Kit (PDF)
• Caries Risk Assessment Form (PDF)
• Dentist Referral to Medical Provider (PDF)
• Fluoride Varnish Application Attestation Form (PDF)
• Fluoride Varnish Training Tool (PDF)
• Fluoride Varnish Toolkit (PDF)
• PCP Fluoride Varnish Application Update (PDF)
• Pediatric Medical-to-Dental Provider Care Referral (PDF)
• Medical Clearance for Dental Treatment (PDF)
• Medical Provider Referral to Dentist (PDF)

Pharmacy

• Coverage Determination Request Form (PDF)
• Oral Enteral Nutrition Request Form (PDF)
• Medical Drug Authorization Request (PDF)
• Medication Appeal Request Form (PDF)
• Synagis Prior Authorization Request Form (PDF)

Other Forms

• Consent for Sterilization (PDF)
• Custodial Authorization Form (PDF)
• Hysterectomy Receipt of Information (PDF)
• Institutional Risk Screen Tool (PDF)
• PCP Request for Transfer of Member (PDF)
• Refund Check Information Sheet (PDF)
• Refund Referral Grid (PDF)
• Requesting Interpreter Services Form (PDF)
• SCNF Authorization Request Form (PDF)