Forms

Access key forms for authorizations, claims, pharmacy and more.

Physician/Allied Contract Packet

If you provide services such as primary care, specialist care, mental health, substance abuse and more, please download and complete the forms below:

• Medicaid Cover Letter
• Medicaid Participating Provider Agreement
• W-9 Form

Ancillary Contract Packet

If you provide services such as home health, Personal care services, hospice, DME, Inpatient services and more, please download and complete the forms below:

• Medicaid Cover Letter
• Medicaid Ancillary Provider Agreement
• W-9 Form

Provider Resources

• Provider Incident Report Form
• PCP Change Request Form for Prepaid Health Plans (PHPs)
• Medication Appeal Request Form
• Refund Check Information Sheet
• YMCA Provider Referral Form (Diabetes Prevention Program/Healthy Weight and Your Child)
• Medicaid Drug Coverage Request Form
• Notice of Pregnancy Form
• Inpatient Fax Cover Letter
• Provider Referral Form: LTSS Request for PCS Assessment
• Provider WW/Curves Baseline Fax Form

Prior Authorization Forms

• Medicaid Prior Authorization Request
• Medicaid Pharmacy Prior Authorization Request: ASAP
  
• Medicaid Pharmacy Prior Authorization Request: A+ KIDS
• Value-Added Benefit Referral Form
• Adulhelm
• Adulhelm Prior Approval Request
• Ankylosing Spondylitis (Enbrel, Humira, Simponi,Taltz)
• Antiemetics (Emend and Aprepitant)
• Antiparkinson’s Agents: Inbrija and Ongentys
• Austedo
• Cryopyrin-Associated Periodic Syndromes including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) (Arcalyst and Ilaris)
• Cialis
• Continuous Glucose Monitors
• Crinone 8% Gel
• Crohn’s Disease-Adult (Humira, Cimzia, Entyvio, Inflectra, Stelara, Remicade, Renflexis)
• Crohn’s Disease-Pediatric (Humira, Inflectra, Remicade, Renflexis)
• Cystic Fibrosis (Kalydeco, Orkambi, Symdeko, and Trikafta)
• Deficiency of Interleukin-1 Receptor Antagonist (DIRA) (Arcalyst and Kineret)
• Dupixent for Asthma
• Dupixent for Atopic Dermatitis
• Dupixent for Nasal Polyps 
• Emflaza
• Entresto
• Epclusa
• Epinephrine Pens
• Epidiolex 
• Evrysdi
• Exondys 51
• Familial Mediterranean Fever
• Fasenra
• Gattex
• Giant Cell Arteritis
• Gocovri and Osmolex ER
• Growth Hormone (Adult 21 Years of Age and Older)
• Growth Hormone (Children Less than 21 Years of Age)
• Harvoni
• Hematinics: Procrit/Epogen/Aranesp/Mircera/Retacrit
• Hetlioz/Hetlioz LQ
• Hidradenitis Suppurativa (Humira)
• HIDS MKD
• Immunomodulators: Cytokine Release Syndrome (Actemra Infusion and Actemra SQ)
• Ingrezza
• Ivermectin
• Juxtapid
• Lupus (Benlysta)
• Lupus (Lupkynis)
• Mavyret
• Migraine Calcitonin Agents (Ubrelvy and Nurtec)
• Migraine Calcitonin Gene Related Therapy Agents (Aimovig, Ajovy, Emgaltiy, Vyepti)
• Neonatal Onset Multi-System Inflammatory Disease - NOMID (Kineret)
• Neuromuscular Blocking Agents (Botox, Dysport, Myobloc, Xeomin)
• Neuromyelitis Optica Spectrum Disorder
• Non-Covered Request Form for Recipients under 21 Years Old
• Non Radiographic Axial Spondyloarthritis
• Non-Infectious Intermediate Posterior Panuveitis
• Nucala
• Opioid Analgesic (Long-Acting)
• Opioid Analgesic (Short-Acting)
• Opioid Dependence Therapy Agents
• Oral Ulcers
• PCSK9 Inhibitors
• Polyarticular Juvenile Idiopathic Arthritis (Enbrel, Humira, Actemra SQ, Actemra Infusion, Orencia Infusion and Orencia SQ)
• Plaque Psoriasis-Adult (Enbrel, Humira, Cosentyx, Cimzia, Ilumya, Inflectra, Otezla, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, and Tremfya)
• Plaque Psoriasis-Pediatric (Enbrel and Stelara)
• Provigil and Nuvigil
• Psoriatic Arthritis (Enbrel, Humira, Inflectra, Cosentyx, Cimzia, Orencia, Orencia Infusion, Otezla, Renflexis, Remicade, Simponi, Simponia Aria, Stelara, Taltz, Xeljanz)
• Rheumatoid Arthritis (Enbrel, Humira, Actemra Infusion, Actemra SQ, Cimzia, Inflectra, Kevzara, Kineret, Olumiant, Orencia Infusion, Orencia SQ, Remicade)
• Sedative Hypnotics
• Selective Constipation Agents (Relistor)
• Systemic Onset Juvenile Idiopathic Arthritis (For Actemra SQ, Kineret and Ilaris)
• Sofosbuvir-Velpatasvir
• Standard Drug Request
• Sovaldi
• Stills Disease
• Sunosi
• Synagis
• Topical Local Anesthetics (Lidoderm Patch, lidocaine patch, and ZT Lido)
• Topical Anti-Inflammatory Medications
• Topical Antihistamines
• Topical Antifungal Agents (Vusion)
• Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) 
• Triptans
• Ulcerative Colitis (Adult)
• Ulcerative Colitis (Pediatric) Remicade
• Viekira
• Vosevi
• Vyondys 53 and Viltepso
• Wakix
• Xenazine and Tetrabenazine
• Xolair
• Xolair for Nasal Polyps
• Xyrem
• Xywav
• Zepatier
• Zolgensma