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Medicaid Providers

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Forms

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

Claims

Refund Check Information Sheet* (RCIS)

HEDIS Information

Member Forms

You must complete the attached baseline form before the member begins the program.

Please complete the OUTCOME* and DATE* columns of the form with the member’s current outcome data.

In order to begin the program, members will need to have you complete the attached baseline form.

Please complete the OUTCOME* and DATE* columns of the form with the member’s current outcome data.

Pregnancy/OB Forms

Provider Forms

Alternative Therapies for Chronic Pain Management Referral Form

Chlamydia is the most common sexually transmitted bacterial infection (STI) in the United States. The best way to detect chlamydia in its early stages is to conduct screenings at yearly physicals for patients who are sexually active.

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Last Updated On: 12/17/2020