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Forms

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

Administrative Review

Our primary objective is to help improve our members’ quality of life by educating them and empowering them to adopt a healthier lifestyle. When they make behavioral changes, their chronic conditions can be more successfully managed.

Members who successfully decrease their BMI by one point will be eligible to enroll in an additional three-month Curves Complete Program.

Complete this request in its entirety and attach all supporting documentation, including pertinent medical records and office notes.

Authorizations

Behavioral Health

This document includes Harmony and WellCare covered services and authorization guidelines for Community Mental Health Center (CMHC) Services.

This document includes Harmony and WellCare covered services and authorization guidelines for Division of Alcoholism and Substance Abuse (DASA) Services.

Harmony/WellCare IET referral (Engagement Appointment)

Harmony/WellCare IET referral (Initial Appointment)

Residential Treatment Request Form

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Members can earn $20 if they attend 6 or more prenatal visits before the birth of the baby. Print this form and complete the information with the member in order to earn the reward.

Pharmacy

Other Provider Forms

Complete and submit this form for members who complete healthy behaviors.

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Last Updated On: 5/8/2017
On September 1, 2018, our premium payment services changed. These changes will make it easier for you to pay your premium. Read more. ×