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Home > Welcome Providers > Resources > Provider Forms

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)
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Coverage by Vista Health Plan, Inc. d/b/a AmeriHealth First.

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