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Forms

Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us. 

Claims Forms

icon PDF Participating Provider Claim Dispute Form

Provider Network Forms

icon PDF Add a Practitioner Form
icon PDF Primary Care Provider Panel Change Request
icon PDF Provider Termination Request Form
icon PDF Practice Demographic Form
icon PDF Group/Provider Additional Address Form
icon PDF Provider Tax ID Change Request Form
icon PDF Provider Information Change Form
icon PDF Registration of Locum Tenens Physician Form

Non-Participating Provider Forms

icon PDF Waiver of Liability Form
icon PDF Level One Provider Appeal Form
icon PDF Registration for Non-Participating Providers

Utilization Management Forms

icon PDF Medicare PA Guide
icon PDF Medicare PA Form
icon PDF Medicare BH PA Form
icon PDF Medicare Pharmacy PA Form

Behavioral Health Forms

icon PDF Psychological & Neuropsychological Testing Request
icon PDF Psychological and Neuropsychological Assessment Supplemental Form

Pharmacy Forms

Passport Advantage

icon PDF 2022 Rx Mail Order Form
icon PDF 2022 Redetermination Form

Passport Medicare Choice Care (HMO)

icon PDF 2022 Coverage Determination Request Form
icon PDF 2022 Rx Mail Order Form
icon PDF 2022 Redetermination Form


  

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  • last updated: 02/20/2020

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