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.
  • ERA and EFT Combined Enrollment 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.
  • 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