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Provider Forms
Find general Priority Health forms for providers below.
On other pages in this section you'll find:
Authorization/medical necessity forms for drugs
Authorization forms for services and devices
FDA Medwatch
forms for reporting adverse drug reactions
Medicare payer
sheets
Specialty pharmacy injectable drug request
fax forms
AIM Imaging RQI Number Request fax form
(38KB PDF)
Appointment Of Representative
(
Priority
Medicare) (55KB PDF)
Authorization Guidelines
(
Priority
Medicare) (23KB PDF)
Behavioral Health / PCP Coordination of Care
(407KB PDF)
CPT Code Add Request form
(31KB PDF)
Direct Deposit/Electronic Funds Transfer (EFT) Agreement
(133KB PDF)
Domestic Violence Screening Questions & Documentation
(228KB PDF)
Electronic Claim Registration Form
(33K PDF)
Filemart Report Request
(16KB PDF)
Group Therapy Request
(16KB PDF) (Behavioral Health provider use only)
Health
byChoice Incentives f
orms:
Paper Qualification Form
(79KB PDF)
Online Qualification Form
HIPAA Authorization
(33KB PDF)
HIPAA Authorization, Spanish
(34KB PDF)
HIPAA Revocation of Authorization
(32KB PDF)
HIPAA Revocation of Authorization, Spanish
(30KB PDF)
Home Health Care Services discharge form
(21KB PDF)
Immunization Exception Documentation, Childhood and Adolescent
(immunization refusal waiver) (22KB PDF)
Medical Services Coverage (9/02/2008: This form is being revised and will be replaced later in September)
Medical Services Questionnaire
(402KB PDF)
Modifier 22 Explanation form
(154KB DOC)
NPI Number Notification form - Individual Practitioner (Type 1)
(116KB DOC)
NPI Number Notification form - Group (Type 2)
(115KB DOC)
Notice of Medicare Non-Coverage form
(38KB PDF)
Patient Discharge form
(38KB PDF)
Preliminary Provider Information form
(Behavioral Health providers only) (131KB PDF)
Prior Authorization Request fax form
(32KB PDF)
Provider Demographic Change Notification form
(17KB PDF)
Provider Demographic Change Notification form, behavioral health providers
(117KB DOC)
Provider Dispute Resolution
(33KB PDF)
Referral to Non-Participating Provider
(54KB PDF)
Refund Check form
(152KB PDF)
Well child exam forms:
Well Child Medical History form
(86KB PDF)
Well Child 0-4 Week Exam form
(105KB PDF)
Well Child 2 Month Exam form
(105KB PDF)
Well Child 4 Month Exam form
(105KB PDF)
Well Child 6 Month Exam form
(106KB PDF)
Well Child 9 Month Exam form
(104KB PDF)
Well Child 12 Month Exam form
(105KB PDF)
Well Child 15 to 18 Month Exam form
(105KB PDF)
Well Child 2 Year Exam form
(105KB PDF)
Well Child 3 Year Exam form
(104KB PDF)
Well Child 4 Year Exam form
(104KB PDF)
Well Child 5 Year Exam form
(103KB PDF)
Well Child 6 to 10 Year Exam form
(103KB PDF)
Well Child 11 to 14 Year Exam form
(103KB PDF)
Well Child 15 to 20 Year Exam form
(105KB PDF)
Last modified
09/02/08
