Forms
Access key forms for authorizations, claims, pharmacy and more.
Administrative Review
Authorization
- 2023 Prior Authorization Form (PDF)
- Authorization to Exchange Confidential Information (PDF)
- CCFFH/E-ARCH/CCMA Authorization Request Form (PDF)
- CIS Member Consent Form (PDF)
- CIS Referral Form (PDF)
- Consent for Voluntary Sterilization DHS 1146 (PDF)
- Consent for Voluntary Sterilization Instructions (PDF)
- Delivery Notification (PDF)
- HCBS Authorization Request Provider (PDF)
- Inpatient Authorization (PDF)
- Inpatient Fax Cover Letter (PDF)
- Medical Drug Authorization Request Form (PDF)
- Notice of Pregnancy Form (PDF)
- Oral Nutrition Request Form (PDF)
- Outpatient with Travel Authorization Request (PDF)
- Transplant Authorization Request (PDF)
- Transportation Request (PDF)
Behavioral Health
- 10 Day Adverse Event Conference Form (PDF)
- Adverse Event Report Immediate Notification Form (PDF)
- Assessment, Screening and Monitoring Tool for Pediatric Members Prescribed an Atypical Antipsychotic Medication (PDF)
- BH Case Management Authorization for Supported Employment and Peer Support (PDF)
- BH Case Management Authorization for Representative Payee (PDF)
- BH Case Management Authorization Request for Supportive Housing (PDF)
- BH Case Management Status Change Notification (PDF)
- BH Service Request Form: Electroconvulsive Therapy Services as Covered (PDF)
- Notice of Non-Disclosure of Minor-Initiated Mental Health Care (PDF)
- PHP and IOP Services as Covered (PDF)
- Psychosocial Rehab Authorization Request (PDF)
- Serious Mental Illness SMI Referral Instructions (PDF)
- Specialized Residential Treatment SRT Authorization (PDF)
- Steps for Root Cause Analysis (PDF)
Claims
- CMS 1500 Submission Sample (PDF)
- Non Claim Remit Cost Share Collection (PDF)
- Refund Check Information Sheet (PDF)
- Refund Check Informational Grid (Multiple Refunds) (PDF)
- Taxonomy Guide (PDF)
- UB-04 Submission Sample (PDF)
Medical Records
Pharmacy
- Hepatitis C Treatment Prior Authorization Request Form (PDF)
- Medical Drug Authorization Request Form (PDF)
- Medicaid Medication Coverage Determination Request (PDF)
- Medicaid Medication Appeal Request (PDF)
- Synagis Prior Authorization Form (PDF)
- Zubsolv Prior Authorization (PDF)
Other Forms
- Delivery Notification (PDF)
- Disclosure of Ownership and Control Interest Statement (PDF)
- ESPDT Toolkit Guide (PDF)
- Health Services Referral Form (PDF)
- Hysterectomy Acknowledgement DHS 1145 (PDF)
- Hysterectomy Acknowledgement Instructions (PDF)
- Incontinence Supply Order Form (PDF)
- Medical Necessity of Mode of Transportation Certification (PDF)
- PCP Request for Transfer of Member (PDF)
- Pain Management Program Provider Referral Form (PDF)
- Requesting Interpreter Services Form (PDF)
- Sample Provider Contract (PDF)