Health Care Professional Forms

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

Member Complaint and Appeal
Practitioner and Provider Complaint and Appeal

Dispute Resolution Request
Electronic Claim Submission Application
Statement of Understanding

EFT Only Enrollment
ERA and EFT Enrollment

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)

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 (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

Medical Request

NPI Submission
NPI Exemption Notification

Infertility Program Patient Registration

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.

• Eye Examination Report Form
• Physician Communication Form
• Physician Communication Post-Fragility Fracture Care Form
• Specialist Consultation Report 
• Behavioral Health/Medical Provider Communication Form

Provider Demographic Updates

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