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

Appeals & Grievances


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

Behavioral Health Forms


Refund Check Information Sheet* (RCIS)

Medical Records


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: 1/9/2020
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