Provider Forms

• Appoint a Provider Request Form (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.
• 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.
• Fee Schedule Request: Fill out this form to request fee schedule data for the period of July 1, 2026 - June 30, 2027.
• 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 Form (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.
• Reconsideration Request Form (pdf): Submit this form to request that a denied claim be reconsidered for reimbursement.