Access key forms for authorizations, claims, pharmacy and more.
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 Service Request Form
Refund Check Information Sheet* (RCIS)
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.
Alternative Therapies for Chronic Pain Management Referral Form