Skip to main content

Medicare Providers

Size

Forms

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

Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

This request will be treated as per the standard organization determination time frames.

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

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

contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 2/4/2021