Forms: For Providers

Provider Resources

• Provider Manual
• Provider Quick Reference Guide

Forms For Provider Services

• Provider Demographic Information Change Request Form
• Provider Recruitment Form

Services Requiring Pre-Authorization

• Ambulatory Surgical Procedures
• Chiropractic Services(refer to Quick Reference Contact Sheet)
• Home Care, Certain Outpatient, DME and RX Services
• Hospital Services

Reference Contact Guides

• Chiropractic Services
• Hospital Services
• Outpatient & Home Care Services
• Prescription Benefit Program

Forms for Authorization

• Service/Equipment Request for Authorization
• Home Oxygen Therapy Request for Authorization
• Prescription Request for Authorization
• PT/OT/ST Benefit Extension