Professional Provider Forms

The following forms can be completed and submitted online.

• Refund/Deduct Authorization (offsite link)
• Claim/Enrollment Inquiry
• Electronic Fund Transfer (EFT) Form (offsite link)
• Other Party Liability
• CAQH Provider ID Request (offsite link)

 The following documents are in PDF format.

• Behavioral Health Provider Areas of Expertise *
• Case Management Referral Form *
  (Form 15-261C)
• Certificates of Medical Necessity
  • For supplies/medical equipment without specific CMN*
    (Form 15-405)
  • Oxygen – This CMN is not required with the claim. It is completed by the ordering physician and maintained in file by the oxygen provider.*
    (Form 15-406)
  • Seat lift chair/patient lift and sit to stand/standing frame systems*
    (Form 15-503)
  • Hospital Bed*
    (Form 15-506)
  • Lymphedema Compressor*
    (Form 15-508)
  • Manual Wheelchair*
    (Form 15-509)
  • Motorized Wheelchair*
    (Form 15-510)
  • Power Operated Vehicle*
    (Form 15-513)
  • Pulse Oximeter*
    (Form 15-514)
  • Support Surfaces (Mattresses and Pads) *
    (Form 15-515)
• Claim Appeal Representative Authorization Form *
  (Form 29-58)
• Disease Management and Wellness Program Referral Form *
  (Form 7-538)
• Limited Patient Waiver *
  (Form 15-169)
• Medical Necessity Form for Periodontal Therapy with a Controlled Chemotherapy Agent *
  (Form 15-721)
• New Directions Psych Testing Form
  (Form 42-4)
• OPL Deduct Authorization Form*
  (Form 29-203)
• Other Party Liability Questionnaire*
  (Form 34-704)
• Predetermination Request Form *
  (Form 15-17)

• Prior Authorization (PA) Forms

   

  • ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial *
  • BRCA1 and BRCA2 Testing *
  • Compounded Prescriptions *
  • Human Growth Hormone *
  • Prior Authorization Request Form *
  • Site of Care Infusion Management *
• Prime Coverage Exception (offsite link)
• Prime Coverage Exception fax form (offsite link)
• Provider Change of Information Form
  (Form 15-141)
• Refund/Deduct Authorization*
  (Form 29-202)
• Request to Receive Service Outside of Solutions Network *
  (Form 15-504)
• Provider Network Enrollment Request*
  (Form 15-481)
• Alteration/Forgery/Unauthorized Signature Affidavit*

* You may fill out and print this form using your acrobat reader program.