Provider Forms
- Chiropractic Evaluation and Treatment Request (PDF)
- Claim Refund Form (PDF)
- DHS MA-112 Newborn Form (PDF)
- Discharge Planning Form (PDF)
- Enrollee Consent Form for Physicians Filing a Grievance on Behalf of a Member (PDF)
- Enteral Request (PDF)
- Environmental Lead Investigations (ELI) Form (PDF)
- Genetic Request (PDF)
- Hospital Notification of Emergent/Urgent Admissions (PDF)
- J & B Medical Incontinence Supply (PDF)
- Mini Nutritional Assessment (PDF)
- OB Delivery Log (PDF)
- Outpatient Therapy/Cardiac and Pulmonary Rehab Request (PDF)
- Pain Management Injection Request (PDF)
- Patient Acknowledgement Form for Hysterectomy (PDF)
- Pennsylvania Application for Benefits (PDF)
- Pennsylvania WIC Program (PDF)
- Pharmacy Formulary Addition/Deletion/Modification Request (PDF)
- Pharmacy Prior Authorization
- Pharmacy Prior Authorization Request Form
- Physician Certification for Abortion (PDF)
- Prior Authorization Request (PDF)
- Provider Change (PDF)
- Recipient Statement (PDF)
- Recipient Statement Under Age 18 (PDF)
- Sterilization Consent (PDF)