Provider Forms

Frequently Used Forms

Claim Form:

• Claim Resubmission Form

Referral Forms:

• Health Tradition Care Plus Plan: In-Network Referral Form
• Health Tradition Care Plus Plan: Out-of-Network Referral Form
• Health Tradition Only: External Referral Request Form

Services that Require Authorization:
Applies to all Health Tradition and Health Tradition Care Plus Plans

• Health Tradition Services Requiring Preauthorization

Authorization Forms:
Applies to all Health Tradition and Health Tradition Care Plus Plans

• Cologuard Prescription Form
• 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
• Preauthorization / Prior-Auth Oncology Request
• Provider Update Form
• Psychological/Neuropsychological Testing Authorization Form
• 65Plus Skilled Nursing Facility Notification Form