Provider Forms

Frequently Used Forms

• Claim Resubmission Form
• Cologuard Prescription Form
• External Referral Request Form
• Health Tradition Services Requiring Preauthorization
• Inpatient Pre-Certification/Notification Form
• Medical Clearance Form for Health Tradition Low Back Pain Program
• Medication Preauthorization Form
• Medication Testing – Hydroxychloroquine
• Medication Testing – Methotrexate
• Medication Testing – Vectra DA

• Pre-Authorization/Prior-Authorization Request Form
• Pre-Authorization/Prior-Authorization – Behavioral Health Form
• Prior Authorization Request for Autism Spectrum Disorder Services
• Provider Update Form
• Psychological/Neuropsychological Testing Authorization Form
• 65Plus Skilled Nursing Facility Notification Form