Provider Forms

• Authorization for Automatic Bank Deposit Form (pdf)
• Electronic Remittance Advice (835) Request Form (pdf)
• Request for Reconsideration (pdf)
• Request to Appoint a Provider (pdf)
• Home Phototherapy Order Form (pdf)

Forms for Clinical Review

• Autoimmune Drug Specific Preauthorization
• Chemotherapy
• Drug Preauthorization Request
• General Medical Preauthorization Request
• Multiple Sclerosis Drug Specific Preauthorization
• Request for Drug Formulary Exception (Pharmacy Policy: Formulary Exception)

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.