Uniform Practitioner Credentialing Application (PDF)
Uniform Facility Credentialing Application (PDF)
Uniform Practitioner Add-Change Form (PDF)
Non-credentialed Practitioner Add Form (PDF)
Non-credentialed Practitioner Change Form (PDF)
Non-credentialed Practitioner Terminate Form (PDF)
Location Add Form (PDF)
Location Demographic/Update Form (PDF)
Location Close Form (PDF)
Provider Notification Change/Update/Termination Third-Party Agreement (PDF)
DME / Supply Prior Authorization Request Form (PDF)
General Prior Authorization Request Form (PDF)
Prior Authorization Genetic Testing Form (PDF)
Hospice Election Communications Form (PDF)
Pre-Determination Request Form (PDF)
Nursing Home/ Swing Bed Admission Notification
Prior Authorization – Mental Health Outpatient Services (PDF)
Substance Use Disorder (SUD) Outpatient Services (PDF)
Prior Authorization for Out-of-Network Mental Health & Substance Use Disorder Services (PDF)
Notification of Inpatient Mental Health Admission (PDF)
Notification of Inpatient Substance Use Disorder (PDF)
Release of Information Form (PDF)
Disease Management Referral Form (PDF)
Care Management Referral Form (PDF)
Provider Claim Reconsideration Request Form (PDF)
Health Care Claim Attachment Cover Sheet (PDF)
Gender Identity Information Form (PDF)
Waiver of Liability Statement (PDF)
Provider Notification Change/ Update/ Termination Third-Party Agreement (PDF)
For all provider-related pharmacy forms, including prior authorizations for medical injectable drugs, please visit the pharmacy page
Notice of Medicare Non-coverage (Advance Notice) (NOMC)
NOMNC Valid Delivery Documentation Form (PDF)
Detailed Explanation of Non-Coverage Form (DENC)
NDMCP – Notice of Denial of Medical Coverage (NDMC)
