Forms

Authorizations & Appeals

• Standard Authorization Request
  • Adobe PDF
  • Word Document


• DEXA Scan
  • Adobe PDF
  • Word Document


• Sleep Study
  • Adobe PDF
  • Word Document


• Glaucoma, Glaucoma Suspect, Ocular HTN and Optic Nerve Cupping
  • Adobe PDF
  • Word Document


• Cataract Authorization Form
  • Adobe PDF
  • Word Document


• Continued Physical Therapy - *New for 2011*
  • Adobe PDF
  • Word Document


• Colonoscopy - *New, March 2012*
  • Adobe PDF
  • Word Document


• CPAP Compliance
  • Adobe PDF
  • Word Document


• Member Grievances, Appeals and Complaints
  • Adobe PDF
  • Word Document

Claims & PDRs

• Provider Dispute Resolution
  • Adobe PDF
  • Word Document


• Claim Status Request
  • Adobe PDF
  • Word Document

Credentialing

• Click here for Credentialing Forms

Other Forms

• Health Education Alliance Referral
  • Adobe PDF
  • Word Document


• Our Pathways to Health Referral
  • Adobe PDF


• POLST Patient Brochure
  • Adobe PDF


• Sample Acknowledgement of Financial Responsibility
  • Adobe PDF


• Mammogram Brochure
  • Adobe PDF