- Provider Website Feedback Form
We want to ensure that your online experience meets your needs.
Quality Compliance Forms
Behavioral Health Forms
- Functional Behavior Assessment Autism Comprehensive Evaluation Request Form
- Behavioral Health Clinical Criteria Set Request Form
- Behavioral Health Practitioner Questionnaire
- Behavioral Health Out-of-Plan Referral Review Request Form
- Chemical Dependency Outpatient Treatment Review (OTR) Form
- Mental Health Outpatient Treatment Review (OTR) Form
- Outpatient Applied Behavioral Analysis Treatment Report
- Transcranial Magnetic Stimulation (TMS) Request Form
Patient Care Forms
- Diabetic Retinal Exam Referral Form Use this form when completing Diabetic Retinal Exam Referrals
- Durable Medical Equipment Preauthorization Form
- Health Care Proxy Form The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.
- Injectable Medication Prior Approval Medical Necessity Form This prior authorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services.
- In-Network Referral Form Fillable form for fax use.
- Health Care Services Referral Form
- Home Health Care Preauthorization Form
- Lead Risk Assessment In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age.
- Med D Coverage Determination Form A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.
- Out-of-Plan Referral Review Request Form
- Preauthorization Form Elective Surgery
- Preauthorization Form: Outpatient Services
- Preauthorization Form: Transplant
- Preauthorization/Non-Formulary Medication Request Form
- Disclosure of History Form
- Disclosure of Ownership and Control Form - Facility
- Disclosure of Ownership and Control Form - Practitioner
- Provider Enrollment Application Checklist
- New Provider Enrollment and Disclosure Form
- Nurse Practitioner Agreement/Acknowledgement
- Primary Care Physician (PCP) Change Form This is a form that providers will supply to the patient/member when they are changing their PCP.
- Provider Demographic Change Form Please submit this form to our Corporate Provider File Department when adding additional office locations to your practice, or if your practice moves from its current location. Please fax the completed form to (844) 769-5876
- Request to Resolve Provider Negative Balance
- Supervision Data Form
- Provider Claim Inquiry Form When submitting a provider inquiry for review, please submit all materials as indicated within the form.