Providers Portal

Online Provider FormsForms

All State Providers
-Adding or Opening an Office Form (PDF)
-Advanced Beneficiary Notice (ABN) (PDF)
-All States Provider Address Form (PDF)
-All States W-9 (PDF)
-Claims Appeal Request Form (PDF)
-Closing an Office Form (PDF)
-Fax Cover Sheet for Claim Attachments (PDF)
-Crosswalk for Common Routine Vision Codes ICD-9 to ICD-10 (PDF)
-Non-Covered Services Liability Acknowledgement (PDF)
-Office Relocation Form (PDF)
-On-Line Access Request (Link)
-On-Line Provider Update Form (PDF)
-Ownership and Control Disclosures Form (PDF)
-Panel Participation Request Form (PDF)
-Prior Notification Form (PDF)
-Replacement Eyewear Acknowledgement (PDF)
-Statement of Controlled Substance Coverage (PDF)
-Suspended Status Acknowledgement Form (PDF)
-Vision Care Eyeglasses Patient Certification Form (PDF)
-Waiver of Liability Form (PDF)
Pre-Authorization Request Forms
-New Hampshire Healthy Families Members Pre-Authorization Form (PDF)
-Pre-Authorization Request for Ambetter from Arkansas (PDF)
-Pre-Authorization Request for California Health & Wellness Members (PDF)
-Pre-Authorization Request for CeltiCare (PDF)
-Pre-Authorization Request for Coordinated Care Members (PDF)
-Pre-Authorization Request for Driscoll Health Plan (PDF)
-Pre-Authorization Request for Home State Health Plan Members (PDF)
-Pre-Authorization Request for Louisiana Healthcare Connections Members (PDF)
-Pre-Authorization Request for Magnolia Health Members (PDF)
-Pre-Authorization Request for UnitedHealthCare (PDF)
-Pre-Authorization Request Form (PDF)
-Pre-Authorization Request for Sunflower Health Plan (PDF)
-Pre-Authorization Request for UnitedHealthcare Community Plan of Kansas (PDF)
-Prior Authorization Request for Superior (PDF)
Kansas Provider Forms
-Claims Appeal Request Form for KanCare Members (PDF)
-Kansas Ownership and Control Disclosures Form (PDF)
Ambetter from Arkansas Health and Wellness Provider Resources
-Blepharoplasty, Ptosis and Canthoplasty (PDF)
-Attachment A Blepharoplasty Ptosis Repair (PDF)
-Cataract Extraction (PDF)
-Attachment A Cataract Extraction.pdf (PDF)
-Cataract Extraction-Second Eye (PDF)
-Attachment A Cataract Extraction-Second Eye.pdf (PDF)
-Complex Cataract (PDF)
-Attachment A Complex Cataract.pdf (PDF)
-YAG Laser Capsulotomy (PDF)
-Attachment A YAG Laser Capsulotomy (PDF)
-Pre-Authorization Statistics for July, August, September 2015 (PDF)
Frame Formulary
-Community First Marketplace Frame Formulary (PDF)
-Marketplace Frame Formulary (PDF)
Adult Body Mass Index (BMI) Assessments
-Body Mass Index Table (PDF)
-Understanding Your Weight Loss Options (PDF)
Puerto Rico Provider Forms
-Adding or Opening an Office Form (PDF)
-Closing an Office Form (PDF)
-Disclosure of Ownership and Control Interest Statement (PDF)
-Electronic Claims Submission through Inmediata (PDF)
-Non-Covered Service Liability Acknowledgment Form (PDF)
-Office Relocation Form (PDF)
-EVB Puerto Rico Prior Notification Form (PDF)
-Provider Address Form (PDF)
-Statement of Controlled Substance Coverage Form (PDF)
-W9 Form (PDF)
Miscellaneous Plan Forms
-UPMC Health Plan Non-Covered Services Agreement (PDF)
-California Health & Wellness Replacement Frames Acknowledgement (PDF)

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