Provider Forms

ABA Universal Request Form

Children’s HCBS Authorization Request Form

CORE Provider Service Initiation Notification Form

Home Care Services Request Form

Managed Long Term Care (MLTC)

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

Medication Prior Authorization Form

Medicare Coverage Determination Request Form

General Medical Authorization Form
(exclusion may apply to some plans)

Medicare Redetermination Request Form

Outpatient Therapy Request Form

Physician Administered or Infusion Drug Form

Specialty Medication Prior Authorization Form

Growth Hormone Prior Authorization Request Form

Hepatitis C Prior Authorization Request Form

DME 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