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Resources - View Forms and Documents Top Page Content
Use the links below to print/view copies of our most frequently used forms. If you have questions, please contact Customer Care at 1(866) 265-5983.
Resources - View Forms and Documents Accordion Content
- Children and Family Treatment & Support Services Intake FormOpen a PDF
- Children's Home and Community-Based Services Intake Form Open a PDF
- Confirmation of Pregnancy FormOpen a PDF
- Easy Care Referral FormOpen a PDF
- Group Therapy Format Description FormOpen a PDF
- Group Therapy Description Form for DBTOpen a PDF
- GroupTherapyProposalsOpen a PDF
- MRI/MRA, CT/CTA & Nuclear Cardiology FAX Request FormOpen a PDF
- Non-Emergent Left Heart Cardiac Catheter Preauthorization FormOpen a PDF
- PET FAX Request FormOpen a PDF
- Preauthorization for Medical Necessity FormOpen a PDF
- Referral FormOpen a PDF
- UM Initial Determination Timeframes - Commercial ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicaid & Safety Net ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicare ProductsOpen a PDF
- Member Care Management Program Referral FormOpen a PDF
- Request for Grievance or AppealOpen a PDF
- Court Ordered Treatment: Certification Form for Mental Health and Substance Use DisordersOpen a PDF
- Physician's Order for Personal Care Services (DOH-4359) Open a PDF
- Claim Adjustment or Retraction Request FormOpen a PDF
- APC Pricing Dispute FormOpen a PDF
- APG Pricing Dispute FormOpen a PDF
- Claims Status Request FormOpen a PDF
- DRG Review Request Inquiry FormOpen a PDF
- Indemnity System Remittance Field DescriptionsOpen a PDF
- Managed Care System Remittance Field DescriptionsOpen a PDF
- Managed Care System Remittance Explanatory CodesOpen a PDF
- InstaMed Order FormOpen a PDF
- Request for Timely Filing ReviewOpen a PDF
- Tips for Accurate and Complete CodingOpen a PDF
- Analysis and Recovery Audit - Provider Request for Review FormOpen a PDF
Prescription Drugs
Medical & Behavioral Health
- Outpatient Prior Authorization FormOpens a PDF
- Inpatient Prior Authorization FormOpens a PDF
- Adult Behavioral Health Home and Community Based Services Prior/Continuing Authorization FormOpens a PDF
- Behavioral Health Outpatient Treatment Request Form
- Inpatient and Outpatient Neuropsychological and Psychological Testing Authorization FormOpens a PDF
