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Health Care Provider Forms

General


FormDescription
Claim Review Fillable 
Coordination of Benefits Online Questionnaire
Interactive Questionnaire 
Corneal Transplant Predetermination Request Interactive 
Instructions 
Dependent Student Medical Leave Certification Form  
Hemophilia Referral Fax  Interactive
Hospital Coverage Letter  Interactive
Medicare Reconsideration  Fillable
PPO Notification for non pre-cert surgeries per Texas Administrative Code 3.3703   
Predetermination Request  Fillable
Proton Beam Therapy Radiation Physician Worksheet  Fillable
Prior Authorization   
Provider Refund  Fillable
Room Rate Update Notification   
Synagis Statement of Medical Necessity  Fillable
Verification Request Interactive 


Medical Policy Forms (Note: May be used as a supplement to medical record documentation)


FormDescription
Bariatric Surgery  Interactive
Botulinum Toxin  Interactive
Cranial Remolding Orthosis (CRO) Device  Interactive
Erythropoiesis-Stimulating Agents (ESAs)  Fillable
Genetic Testing  Instructions 
Fillable
Growth Hormone  Interactive
Hyperbaric Oxygen (HBO) Pressurization  Interactive
Immunoglobulin Therapy  Interactive
Oncotype DX  Interactive
PAVETTM Evaluation for Microprocessor Knee  Interactive
Remicade  Interactive
Varicose Vein Management  Interactive
Wheelchair Medical Necessity and Home Evaluation Verification  Interactive


Behavioral Health


FormDescription
ABA Services Specialty   
Clinical Update Request   
Coordination of Care   
Electroconvulsive Therapy (ECT) Request   
Intensive Outpatient Program (IOP) Request   
Outpatient Treatment Request (OTR)   
Psychological/Neuropsychological Testing Request   
Repetitive Transcranial Magnetic Stimulation (rTMS)    
Transitional Care Request   


Pharmacy

FormDescription
PrimeMail New Prescription Fax Order   
Prime Specialty Pharmacy Fax Form   
Quantity Limit Override Request   
Topical Verapamil Override Request