Forms
Access key forms for authorizations, claims, pharmacy and more.
Administrative Review
- Administrative Review Request Member - English (PDF)
- Provider Administrative Review Request - English (PDF)
- Member Data Change - English (PDF)
Authorization
- Consent for Voluntary Sterilization DHS 1146 - English (PDF)
- Consent for Voluntary Sterilization Instructions - English (PDF)
- DME Authorization Request Form - English (PDF)
- Skilled Therapy Services Prior Authorization Form - English (PDF)
- Transplant Authorization Request - English (PDF)
- Delivery Notification Form - English (PDF)
- HCBS Authorization Request Provider - English (PDF)
- Inpatient Authorization - English (PDF)
- Inpatient Fax Cover Letter - English (PDF)
- Notice of Pregnancy Form - English (PDF)
- Oral Nutrition Request Form - English (PDF)
- Transportation Request - English (PDF)
- Outpatient with Travel Authorization Request - English (PDF)
- Outpatient without Travel Authorization Request - English (PDF)
- Telemedicine Authorization Request - English (PDF)
Behavioral Health
- 10 Day Adverse Event Conference Form - English (PDF)
- Adverse Event Report Immediate Notification Form - English (PDF)
- Assessment, Screening and Monitoring Tool for Pediatric Members Prescribed an Atypical Antipsychotic Medication - English (PDF)
- Behavioral Health Case Management Authorization - English (PDF)
- Behavioral Health Case Management Authorization for Representative Payee - English (PDF)
- Behavioral Health Case Management Authorization Request for Supportive Housing - English (PDF)
- Behavioral Health Case Management Status Change Notification - English (PDF)
- Behavioral Health Service Request Form: Electroconvulsive Therapy Services as Covered - English (PDF)
- PHP and IOP Services as Covered - English (PDF)
- Psychosocial Rehab Authorization Request - English (PDF)
- Serious Mental Illness SMI Referral Instructions - English (PDF)
- Specialized Residential Treatment SRT Authorization - English (PDF)
- Steps for Root Cause Analysis - English (PDF)
Claims
- CMS 1500 Submission Sample - English (PDF)
- Non Claim Remit Cost Share Collection - English (PDF)
- Refund Check Information Sheet - English (PDF)
- Refund Check Informational Grid (Multiple Refunds) - English (PDF)
- Taxonomy Guide - English (PDF)
- UB-04 Submission Sample - English (PDF)
Medical Records
Pharmacy
- Hepatitis C Treatment Prior Authorization Request Form - English (PDF)
- Medicaid Coverage Determination Request - English (PDF)
- Medicaid Medication Appeal Request - English (PDF)
- Synagis Prior Authorization Form - English (PDF)
- Zubsolv Prior Authorization - English (PDF)
- Medical Drug Authorization Request - English (PDF)
Other Provider Forms
- Delivery Notification - English (PDF)
- Disclosure of Ownership and Control Interest Statement - English (PDF)
- Health Services Referral Form - English (PDF)
- Hysterectomy Acknowledgement DHS 1145 - English (PDF)
- Hysterectomy Acknowledgement Instructions - English (PDF)
- Incontinence Supply Order Form - English (PDF)
- Medical Necessity of Mode of Transportation Certification - English (PDF)
- PCP Request for Transfer of Member - English (PDF)
- Pain Management Program Provider Referral Form (PDF)
- Requesting Interpreter Services Form - English (PDF)
- Sample Provider Contract - English (PDF)