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 Provider Resources

Prior Approval/Prior Authorization Forms
Prior Approval for Out of State/Out of Network Services
Precertification for Services
Orthodontia Precertifcation Form
Endodontic Precertification Form
Prior Approval Request for Prescriptions
Prior Approval Request Form for ADD Medications

Medical Home Program
Medical Home Provider Application
Medical Home Provider Directory
Medical Home Selection Form   (for members)

Prescription Drug Plan
Current Preferred Drug List (Alphabetical)
Current Preferred Drug List (By Drug Type)
Prior Approval Request for Prescriptions
Prior Approval Request Form for ADD Medications
Prior Approval Request Form for Antipsychotics Medications, and Guidelines

Immunization Resources
CPT Codes for Immunizations
Immunization Schedule for Ages 0-6 years
Immunization Schedule for Ages 7-18 years

Preventative Care
Dental Care Flyer
Vision Care Flyer
Well-Child Exam Flyer
Child Development Flyer
Hearing Screening Flyer

Healthcheck Forms
Healthcheck Provider Manual and Forms
Kindergarten Screening Document

Dental Information
Dental Provider Guide
Frequently Asked Questions For Dental Services

Provider Payment Authorization
Electronic Funds Transfer Auth (EFT) Form.pdf
Electronic Funds Termination Form

Benefit Resources & Reimbursement
Reimbursement for Developmental Screenings


If there are other forms, or information that would be helpful if listed on this page, please contact us to let us know. 

 

 

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