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Forms

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

Appeals and Grievances

Authorizations

Drug Prior Authorization Requests Supplied by the Physician/Facility

Transplant Authorization Request Form

Behavioral Health

If the MCO is requesting concurrent review before the fourth visit; the CFTSS provider can complete this form when requesting continuation of services.

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

Please use this form to request coverage of a drug that we would not usually cover or would restrict in some way.

Fill out and submit this form to request an appeal for your Medicaid medications.

NYS Medicaid Prior Authorization Request Form For Prescriptions

Quality

Other Forms

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

Complete this form after the member completes the 6-month Weight Watchers program.

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Last Updated On: 8/8/2019