Forms
Helpful forms
- Appointment of Representative
- Non-Par Provider Appeal Form
- Waiver of Liability
- Online Provider Dispute Instructions
- PAR Provider Dispute Form
- Member transition of care form (English/Spanish)
- Member Care Information registration form
- My Care Information member authorization form (English/Spanish)
- Prior authorization form (see attached Prior Authorization List)
- Prescription Drug Mail Order Form (English & Español)
- Medicare Part D Prescription Claim Form (English & Español)
- Pharmacy Coverage Determination Form
- ERA Authorization Enrollment Form
- Wire Authorization Form
- EFT Authorization Enrollment Form
- Gender Affirming Services PA Form