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Forms

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

Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

State-Specific Authorization Forms

Behavioral Health Forms

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Other Provider Forms


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Last Updated On: 2/23/2021