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Forms

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


Appeals & Grievances

Use this form to appoint an individual to act as a representative.

Use this form to dispute a provider payment.

Use this form to file an appeal or dispute based on a claim outcome.

Authorizations

Drug Prior Authorization Requests Supplied by the Physician/Facility

Requests for prior authorization (with supporting clinical information and documentation) should be sent to  ĽOhana 14 days prior to the date the requested services will be performed.

Telemedicine Authorization Request Form

Behavioral Health

Behavioral Health Service Request Form

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

Other Provider Forms


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Last Updated On: 11/25/2019