Provider Forms

ABA Universal Request Form

Children’s HCBS Authorization Request Form

CORE Provider Service Initiation Notification Form

General Medical Authorization Form

(exclusion may apply to some plans)

Home Care Services Request Form

Managed Long Term Care (MLTC)

General Medicaid Medication Prior Authorization Form

General Essential Plan, MarketPlace Plans, SHOP Plans, Gold/GoldCare Plans

Medication Prior Authorization Form

Medicare Coverage Determination Request Form

Medicare Redetermination Request Form

Outpatient Therapy Request Form

Specialty Medication Prior Authorization Form

Growth Hormone Prior Authorization Request Form

Hepatitis C Prior Authorization Request Form

Provider DME Authorization List

Informed Consent for Hysterectomy and Sterilization

Acknowledgement of Hysterectomy – LDSS-3113

Sterilization Consent Form – LDSS-3134

Pay for Performance Brochure

Care for Older Adults Assessment Form

Electronic Visit Verification Form

EFT Enrollment Form