Forms

You’ll find many of the forms you need on this website. However, to make things easier for you, we’ve gathered a few of them together in one place. See below for some of the most common forms you will need as you work with us.

Waiver of Liability (WOL) form

CMS 1500 form

Prior Authorization form   (see attached Prior Authorization list)

Prior Authorization forms (Medicaid)

EFT form

ERA form

PAR Provider Dispute form

Non-PAR Provider Appeal form (Medicaid)

Non-PAR Provider Appeal form (Medicare-Medicaid)

Coverage determination online (Medicare-Medicaid Plan Pharmacy)

Coverage determination form (Medicare-Medicaid Plan Pharmacy)

Coverage redetermination online (Medicare-Medicaid Plan Pharmacy)

Coverage redetermination form (Medicare-Medicaid Plan Pharmacy)

Health Risk Assessment form

Compliance Program Guidelines Provider Attestation