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Provider Forms
Contact your
Network Development Representative
at the
Office Location
nearest you for assistance.
For Medical Providers
Authorization Form for Clinic/Group Billing
(PDF)
Use for notification that a practitioner is joining a clinic or group.
Claim Reconsideration Request Form
(PDF)
Designation of Authorized Appeal Representative
(PDF)
Expedited Appeal Request Form
(PDF)
Notice of Payer Policies and Procedures and Terms and Conditions
(PDF)
Applicable to all individual network participants and applicants.
Patient Waiver Form
(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.
Physician/Supplier Corrected Bill Submission Form
(PDF)
Use when submitting previously finalized (corrected) bills.
Provider Change of Data Form
(PDF)
Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
Provider Refund Form
(PDF)
Use this form to submit a claim refund.
Termination Form for Clinic/Group Billing
(PDF)
Use for notification that a practitioner is leaving a clinic.
For Dental Providers
Dental Agreement effective May 1, 2012
(PDF)
Authorization Form for Clinic/Group Billing
(PDF)
Use for notification that a practitioner is joining a clinic or group.
Provider Change of Data Form
(PDF)
Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
Termination Form for Clinic/Group Billing
(PDF)
Use for notification that a practitioner is leaving a clinic.
Member Dental Claim Form
(PDF)
Accident Form for Dental Injury
(PDF)
Please use this form to file a claim with your medical plan. Accidents are not covered under your dental policy.
Medicare Forms
Medicare Coverage Determination Request
(PDF)
Medicare Part D 2012 Step Therapy Criteria
(PDF)
Medicare Part D Prior Authorization Forms
Medicare Redetermination Request Form
(PDF)
Medicare Part D 2012 Prior Authorization Criteria
Medi-Pak Advantage (PFFS) MA-PD
(PDF)
Medi-Pak Advantage (PPO) MA-PD
(PDF)
Medi-Pak Rx Basic
(PDF)
Medi-Pak Rx Premier
(PDF)