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


The EPSDT Well Child Exam form is intended for providers to utilize when performing a complete well child exam.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Well Child Exam

Forms not signed or completed correctly will not be processed, and primary care provider (PCP) change will not occur. Members can continue to be treated by the requested PCP until change is complete.

Instructions for large groups and IPAs with five or more providers on how to register for the secure provider portal.

Appeals and Grievances

Complete this form to submit an appeal.

Complete this form to submit a grievance.


Complete and submit this form online in order to request a prior authorization.

Print, complete and then mail this form in order to request a prior authorization.

Behavioral Health




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Last Updated On: 3/31/2016