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Forms

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

Authorization Request Forms

Request for authorization: Bariatric Surgery.

In order to ensure our members receive quality care, appropriate claims payment, and notification of servicing providers, please complete this form in its entirety. Please type or print in black ink and submit this request to the fax number below.

Behavioral Health

Behavioral Health Service Request Form

Behavioral Health Service Request Form

Behavioral Health Service Request Form

Behavioral Health Service Request Form

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

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Last Updated On: 6/5/2017
Welcome Prescription Drug Plan members! We have important information to share with you about your 2019 plan. Read More. ×