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Forms

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

Appeals & Grievances

Authorizations

Behavioral Health Forms

Behavioral Health Areas of Specialization

A fillable form documenting behavioral health areas of specialization

Helpful Documents


Contains key phone numbers and information on claims, appeals and more.

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

This list includes the most commonly prescribed medications that were on the 2016 formulary and their preferred 2017 alternatives.

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

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: 5/9/2017