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Forms

Access key forms for authorizations, claims, pharmacy and more.

Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

Medical Admission Fax Cover Sheet

Behavioral Health Forms

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Other Provider Forms


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Last Updated On: 5/12/2021