Provider Forms

Provider credentialing forms

• Credentialing and recredentialing forms
• Non-contracted provider form (PDF)

Medical authorization/notification forms

• Abortion statement form (PDF)
• Consent for sterilization (PDF)
• Delivery notification worksheet (PDF)
• DME request for authorization (PDF)
• Hysterectomy justification (PDF)
• Member consent for provider to file an appeal (PDF)
• Newborn prior authorization form (PDF)
• Pregnancy risk assessment form (PDF)
• Prior authorization form (general) (PDF)
• PT/OT/ST/Chiro request for authorization (PDF)
• Universal 17P authorization form (PDF)

Pharmacy authorization forms

• Pharmacy prior authorization form 
• Physician request form for hepatitis C therapies (PDF)
• Request form for short-acting opioid medications (PDF)
• HCPCS authorization form (PDF)

Behavioral health forms

• Autism spectrum disorder (ASD) treatment request form (PDF)
• Community support service (CSS) authorization request form (PDF)
• Certification of need - psychiatric hospital services for children under 21 (PDF)
• Crisis intervention notification request form (PDF)
• Behavioral health fax form (PDF)
• Behavioral health discharge note (PDF)
• Behavioral health provider data form (PDF)
• Psychological / neurological testing request form (PDF)
• Psychiatric residential treatment facility (PRTF) authorization request form (PDF)
• Substance abuse discharge note (PDF)

SBIRT forms

• SBIRT - authorization to disclose PHI (PDF)
• SBIRT - referral form for DOADAS (PDF)
• SBIRT - referral form for SCMDH (PDF)
• SBIRT - tobacco quitline fax referral form (PDF)
• SBIRT - universal screening tool (PDF)

Other forms

• Authorization to Disclose Protected Health Information (PHI) (PDF)
• Authorization to Disclose Protected Health Information (PHI) - Spanish (PDF)
• Let Us Know program member intervention request form (PDF)
• Personal representative (PDF)
• Physician transfer of member request form (PDF)
• Provider claim dispute form (PDF)
• Provider refund claim form (PDF)
• Treo Solutions dashboards user access request form (PDF)
• Treo Solutions user guide (PDF)