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Forms


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

Medical and Behavioral Health Submissions: For all Medical and Behavioral Health services, please refer to the Innovista portal to determine authorization requirements and submit a request form. For all Pharmacy requests, please log into the Provider Portal to check authorization requirements or submit a faxed request to 888-871-0564 using the forms provided below.

Appeals & Grievances

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

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

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Last Updated On: 2/12/2020