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Applications and forms for health care professionals and their patients.

Behavioral Health Precertification

ABA Requests: Assessment or Service Authorization
Psychological or Neuropsychological Testing
OP Detoxification or OP Electroconvulsive Therapy (ECT)

Dispute and Appeals

Member Complaint and Appeal
Practitioner and Provider Complaint and Appeal

Employee Assistance Program (EAP)

Dispute Resolution Request
Electronic Claim Submission Application
Statement of Understanding

ERA/EFT

EFT Only Enrollment
ERA and EFT Enrollment

Medical Precertification

Autolougous Chondrocyte Implantation
BRCA
Breast Reduction Surgery
Capsule Endoscopy
Dorsal Column Stimulator
Electroencephalographic (EEG) Video Monitoring
Gender Reassignment Surgery
Gynecologic Surgery Power Morcellation
Hip Surgery for Impingement Syndrome
Hyperbaric Oxygen Therapy (HBOT)
Initial Cochlear Implant
Obesity Surgery
Panniculectomy
Proton Beam Radiotherapy
Ptosis Surgery
Spinal Surgery
Uvulopalatopharyngoplasty (UPPP)
Varicose Vein Treatment
Wheelchairs and Power Operated Vehicles (Scooters)

Medicare

Hospital Discharge Appeal Notices
(Note: This is a page on the CMS site that provides information about patient rights as a hospital inpatient. The page includes detailed information and links to CMS forms.)

Part D prescription drug prior authorizations and exceptions

General prescription drug coverage determination
Aranesp® (darbepoetin alfa)
Armodafinil (generic Nuvigil®)
Hepatitis C
Lidocaine 5% Patch and Ointment (generic Lidoderm®)
Linezolid (generic Zyvox®)
Modafinil (generic Provigil®)
Oral ondansetron (oral generic Zofran®)
Procrit® (epoetin alfa)
Regranex® (becaplermin)
Sildenafil (generic Revatio®)
Tracleer® (bosetan)
Topical testosterone
Zolpidem tartrate (generic Ambien® immediate release)
Tier exception (cost-share reduction) request

Network Application Requests

Medical Request

National Provider Identifier (NPI)

NPI Submission
NPI Exemption Notification

Patient Specific

Infertility Program Patient Registration

Physician Communications

We encourage you to send progress notes and discharge summaries to your patients’ other treating practitioners. Use these forms to help you communicate with other physicians.

Provider Demographic Updates

Provider Demographic Updates

State Specific

Washington D.C. Uniform Consultation Referral (Appendix 43-1)

Together, better health

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Health Care Professional Forms

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Behavioral Health Precertification

Dispute and Appeals

Employee Assistance Program (EAP)

ERA/EFT

Medical Precertification

Medicare

Part D prescription drug prior authorizations and exceptions

Network Application Requests

National Provider Identifier (NPI)

Patient Specific

Physician Communications

Provider Demographic Updates

State Specific

Together, better health

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