The forms listed on the menu below are for use by medical providers. These forms are in portable document format (PDF) and allow you to complete the form online, print, sign and mail to the appropriate address with supporting documents. Contact your Network Development Representative at the Office Location nearest you for assistance.

• Authorization Form for Clinic/Group Billing (PDF): Use for notification that a practitioner is joining a clinic or group.
  
  
  
• Exception Letter (PDF): Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines.
  
  
  
• Notice of Payer Policies and Procedures and Terms and Conditions (PDF): Applicable to all individual network participants and applicants.
  
  
  
• Other Insurance/Coordination of Benefits (COB) (PDF): In an effort to reduce the number of claims delayed for the purpose of investigating for other insurance, a COB questionnaire is available for members to provide other insurance coverage information. Please print, complete then mail the COB form to us in order to update your records and prevent claims from being delayed for COB information.
  
  
  
• 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.
  
  
  
• Pharmacy Forms for Medications that have Quantity Limits
  
  
  
• 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.
  
  
  
• Referral Form (PDF): Primary care physicians should use this form to refer a patient to a specialist when a referral is required by the patient's health plan.
  
  
  
• Termination Form for Clinic/Group Billing (PDF): Use for notification that a practitioner is leaving a clinic.