Provider Forms

Provider

Provider Change Form  
The Provider Change Form is used (facilities excluded) when service address, mailing address, billing address or tax ID number is changing. You must include the previous address or tax ID number and a term date.  Entire form must be completed as failure to provide requested information could result in non-Network payments.  EFT information must be updated when a billing address and/or tax ID number is changed. Use the EFT form which is located above to initiate EFT for a new billing address and/or tax ID number.  Be sure to include a voided check or bank letter.

Provider Email Update Form

Additional Office Location Form
The Additional Office Location Form is used (facilities excluded) when a Network provider wants to add another office location.  This form can be used for a new or existing tax ID number.  Always submit a W9 for a new tax ID number.  Use the EFT form which is located above to initiate EFT for a new address and/or tax ID number.  Be sure to include a voided check or bank letter.

Facility

Facility Change Form
The Facility Change Form is used when service address, mailing address, billing address or tax ID number is changing.  You must include the previous address or tax ID number and a term date.  Entire form must be completed as failure to provide requested information could result in non-Network payments.  EFT information must be updated when a billing address and/or tax ID number is changed.  Use the EFT form which is located above to initiate EFT for a new billing address and/or tax ID number.  Be sure to include a voided check or bank letter.

Facility Email Update Form

Facility Additional Location Form
The Facility Additional Office Location Form is used when a Network Facility provider wants to add another location.  This form can be used for a new or existing tax ID number.  Always submit a W9 for a new tax ID number.  Use the EFT form which is located above to initiate EFT for a new address and/or tax ID number.  Be sure to include a voided check or bank letter.

Certification Request Forms

Use these forms to request certification of the specified medical care for your HealthChoice patients. Penalties are applicable for services that are not certified.

• Air Ambulance
• Benlysta
• Chiropractic Treatment
• Durable Medical Equipment (DME)
• Home Health Care
• Hospice
• Infusion Therapy
• Treatment/Medication Request - Do not use this form for medications being picked up at a pharmacy.  Contact Express Scripts at 1-800-753-2851 for pharmacy prior authorization requests.
• Mental Health
• Occupational Therapy
• Osteopathic Physical Medicine Treatment
• Outpatient Chemical Dependency
• Physical Therapy
• Proton Beam Radiation Request
• Speech Therapy
• Synagis Request
• TMD/TMJ Authorization Form