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Medicare Providers

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Forms

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


Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

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

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

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

Behavioral Health

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

This list includes the most commonly prescribed medications that were on the 2016 formulary and their preferred 2017 alternatives.

Below are the most commonly prescribed medications that were on the 2018 formulary and their preferred 2019 alternatives.

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: 12/13/2020