Provider Forms

The forms below are in PDF format. You need Acrobat Reader to view the files.

Online Forms

For your convenience, the below forms can be completed online and submited via this website.

• FEP Outpatient Treatment Plan Form
• Primary Care+ Physician Referral Form

Provider Forms

In an effort to provide online services for providers, we offer the following interactive forms that you can fill out, print and mail or fax to us.

• Appeal Reconsideration Request
• Change of Address
• Check Return
• Check Tracer
• Electronic Remittance Advice and Electronic Funds Transfer
• Extend-Transfer Existing Agreements
• Federal Employee Program Outpatient Treatment Plan
• NPI Individual Notification
• NPI Organization Notification
• Preauthorization Request
• Primary Care+ Referral Authorization
• Reconsideration Request, Appeal
• Room Rates, Listing of
• TRICARE Behavioral Health Supplement
• TRICARE with Areas of Interest
• Trading Partner Agreement
• Trading Partner Registration
• Universal COB Questionnaire (this form is currently not interactive)
• Universal Provider Application

Pharmacy Pre-auth Request and Enrollment Forms

In an effort to provide online services for providers, we offer the following interactive forms that you can fill out, print and mail or fax to us.

• Amevive and Raptiva PA Physician Fax
• COX-2 Medication Preauthorization Request
• Leukotriene Modifiers (LM) PA Physician Fax
• Migraine PA Physician Fax
• PrimeMail Pharmacy
• Proton Pump Inhibitors PA Physician Fax
• Retinoids (Topical Acne Agents) PA Physician Fax
• Growth Hormone Physician Fax
• Specialty Medication Enrollment Form
• Synagis PA Physicians Fax
• Xolair PA Physician Fax