Claims Forms

• Claims Issue Form
• Third Party Liability Lead Form

Provider Network Forms

• Add A Practitioner Form
• Primary Care Provider Panel Change Request
• Provider Termination Request Form
• Practice Demographic Form
• Group/Provider Additional Address Form
• Provider Tax ID Change Request Form
• Provider Information Change Form
• Referral Form
• Registration of Locum Tenens Physician Form
• Level One Provider Appeal Form

Utilization Management Forms

• Medical Prior Authorization Request Form
• Mental Health/Substance Abuse Outpatient Treatment Review Form
• Outpatient Treatment Review: Applied Behavior Analysis
• Psychological & Neuropsychological Testing Request 

Pharmacy Forms

• 2018 Step Therapy Criteria 
• 2018 Prior Authorization Criteria
• Coverage Determination Request Form
• Request for Redetermination Form