Forms

Below is a list of forms used in day-to-day interactions with our Plan. Visit this section regularly to ensure you have the latest copy.

Provider Forms

• PCP Request for Member Transfer
• Pharmacy Prior Authorization / Drug Exception
• Health Risk Assessment Tool
• Part B Drugs List (Authorization Not Required)
• Specialty Medication Form
• UM Referral Form
• Pre-Certification Request Form
• DEA Protocol Form
• Provider Grievance Form
• Waiver of Liability