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

• Immunization Record - English (PDF)
• Medication Profile - English (PDF)
• Problem List - English (PDF)

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)