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Forms

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

Appeals and Grievances

Authorizations

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

NYS Medicaid Prior Authorization Request Form For Prescriptions

Quality

Other Forms

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

Complete this form after the member completes the 6-month Weight Watchers program.

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Last Updated On: 5/8/2017