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Forms

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

Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

Medical Admission Fax Cover Sheet

State-Specific Authorization Forms

Behavioral Health Forms

Illinois Behavioral Health Forms


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)

Claims

Refund Check Information Sheet* (RCIS)

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

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: 5/12/2021