Provider Forms

  • Authorization for Automatic Bank Deposit Form (pdf): Fill out this form to have insurance payments directly deposited into your clinic/business bank account.
  • Electronic Remittance Advice (835) Request Form (pdf): An electronic remittance advice (ERA) is an explanation from the health plan to a provider about a claim payment. Use this form to request to receive these forms through eProvider Solutions.
  • Request for Reconsideration (Word): Submit this form to request that a denied claim be reconsidered for reimbursement.
  • Request to Appoint a Provider (pdf): This form signed by patient/member and provider to appoint the provider to pursue appeals of full or partial payment on the patient/member’s behalf.
  • Home Phototherapy Order Form (pdf): This physician’s written order for home phototherapy is needed for health insurance approval of this treatment.
  • Cost Estimate – Pre-Determination Request (pdf): A request made by the provider to the health insurance company to determine how much of a billed amount would be covered. This is an estimate and does not guarantee benefits or payment of services.

Forms for Clinical Review

Member Information

Additional preauthorization forms are located within the member-specific preauthorization page. Providers will need a member ID card to identify the group number to access.

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