Forms/Tools

Behavioral Health

• BH Initial Request for Treat. Auth Form
• BH Follow Up Request for Treat. Auth Form

Provider Forms

• Provider/Physician Roster
• Existing Practice Group Participation Request Form
• Provider Info Release
• Physician Assistant Delegation of Services Agreement
• New Practice Group Participation Request Form
• Ancillary Facility Application
• W-9 Form
• Demographic Update Form
• Termination-TIN Change Form
• PCP Panel Closure Request Form
• PQI Notification Form

Other

• Provider Manual