Forms

Access key forms for authorizations, claims, pharmacy and more.

Ancillary Contract Packet

If you provide services such as home health, Personal care services, hospice, DME, Inpatient services and more, please download and complete the forms below:

• Medicaid Cover Letter (PDF)
• Medicaid Ancillary Provider Agreement (PDF)
• W-9 Form (PDF)

Physician/Allied Contract Packet

If you provide services such as primary care, specialist care, mental health, substance abuse and more, please download and complete the forms below:

• Medicaid Cover Letter (PDF)
• Medicaid Participating Provider Agreement (PDF)
• W-9 Form (PDF)

Provider Resources

• Prior Authorization Request Form (PDF)
• Supplemental Prior Authorization Form (4+ service codes) (PDF)
• Inpatient Fax Cover Letter (PDF)
• Medication Appeal Request Form (PDF)
• Medicaid Drug Coverage Request Form (PDF)
• Notice of Pregnancy Form (PDF)
• Provider Incident Report Form (PDF)
• Provider Medical Abortion Consent Form (PDF)
• PCP Change Request Form for Prepaid Health Plans (PHPs) (PDF)
• PCP Transfer Request Form (PDF)
• Provider Referral Form: LTSS Request for PCS Assessment (PDF)
• Provider WW/Curves Baseline Fax Form (PDF)
• Refund Check Information Sheet (PDF)
• YMCA Provider Referral Form (Diabetes Prevention Program/Healthy Weight and Your Child) (PDF)
• Requesting Interpreter Services Form (PDF)

Pharmacy Prior Authorization Request Forms