The forms listed on the menu below are for use by medical providers. These forms are in portable document format (PDF) and allow you to complete the form online, print, sign and mail to the appropriate address with supporting documents. Contact your Network Development Representative at the Regional Office nearest you for assistance.

• Authorization Form for Clinic/Group Billing (56 KB PDF): Use for notification that a practitioner is joining a clinic or group.
  
  
• Medicare Coverage Determination Request (140 KB PDF)
  
  
• Medicare Part D 2010 Medications that Require Prior Authorization
  
  
• Medicare Part D 2010 Prior Authorization Criteria (65 KB PDF)
  
  
• Notice of Payer Policies and Procedures and Terms and Conditions (119 KB PDF): Applicable to all individual network participants and applicants.
  
  
• Other Insurance/Coordination of Benefits (COB) (35 KB PDF): In an effort to reduce the number of claims delayed for the purpose of investigating for other insurance, a COB questionnaire is available for members to provide other insurance coverage information. Please print, complete then mail the COB form to us in order to update your records and prevent claims from being delayed for COB information.
  
  
• Patient Waiver Form (11 KB PDF): Use to educate members on services that may not meet the Primary Coverage Criteria of the member’s policy. Waivers allows providers to collect for services that may not be deemed as meeting the Primary Coverage Criteria particularly for services designated as experimental/investigational or which are not for the treatment of a medical condition.
  
  
• Pharmacy Prior Authorization Forms: Use when requesting coverage for drugs that require prior authorization.
  
  
• Physician/Supplier Corrected Bill Submission Form (152 KB PDF): Use when submitting previously finalized (corrected) bills.
  
  
• Provider Change of Data Form (209 KB PDF): Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
  
  
• Provider Refund Form (90 KB PDF): Use this form to submit a claim refund.
  
  
• Termination Form for Clinic/Group Billing (100 KB PDF): Use for notification that a practitioner is leaving a clinic.