Skip to main content

Medicaid Providers

Size

Forms

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

Authorization Request Forms

Alternative Therapies for Chronic Pain Management

Request for authorization: Bariatric Surgery.

In order to ensure our members receive quality care, appropriate claims payment, and notification of servicing providers, please complete this form in its entirety. Please type or print in black ink and submit this request to the fax number below.

Behavioral Health

Behavioral Health Service Request Form

Behavioral Health Service Request Form

Behavioral Health Service Request Form

Behavioral Health Service Request Form

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.

contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 2/4/2019