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Forms

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

Claims

Refund Check Information Sheet* (RCIS)

HEDIS Information

Member Forms

You must complete the attached baseline form before the member begins the program.

Please complete the OUTCOME* and DATE* columns of the form with the member’s current outcome data.

In order to begin the program, members will need to have you complete the attached baseline form.

Please complete the OUTCOME* and DATE* columns of the form with the member’s current outcome data.

Pregnancy/OB Forms

Provider Forms

Alternative Therapies for Chronic Pain Management Referral Form

Chlamydia is the most common sexually transmitted bacterial infection (STI) in the United States. The best way to detect chlamydia in its early stages is to conduct screenings at yearly physicals for patients who are sexually active.

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Last Updated On: 12/17/2020
Medicare Members: Your materials are on the way! We realize you may be waiting to receive some plan materials and we apologize for any delays. Did you know you can go online to our member portal to view Member materials, review your benefits, request or download an ID card, or choose a physician (when applicable)? Log in or register today!
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