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Forms for Providers
Forms for Providers

Use the links below to print/view copies of our most frequently used forms. Forms marked as "East" apply to the Central New York, Central New York Southern Tier and Utica regions.

Quick Tips for Using Correct Forms (PDF)

  • Administration
  • Disclosure of Ownership & Controlling Interest Statement with FAQsOpen a PDF
  • Durable Medical Equipment Upgrade FormOpen a PDF
  • Home & Community-Based Services (HCBS) Status Change FormOpen a PDF
  • Member Consent for Provider Representation During Appeal or Complaint ProcessOpen a PDF
  • Patient End-stage Renal Disease FormOpen a PDF
  • PCP Selection Form for Safety Net MembersOpen a PDF
  • Prenatal Incentive Program Registration Form for Safety Net MembersOpen a PDF
  • Ancillary Services
  • Chiropractic Medical Record Documentation Standards EastOpen a PDF
  • Chiropractic Treatment Plan EastOpen a PDF
  • Benefits Management
  • Applied Behavioral Analysis Provider Request FormOpen a PDF
  • Confirmation of Pregnancy FormOpen a PDF
  • Group Therapy Format Description FormOpen a PDF - (includes Group Therapy Proposal Summary)
  • DBT Group Therapy Format Description Form Open a PDF - (includes Group Therapy Proposal Summary)
  • Easy Care Referral FormOpen a PDF
  • Request for Reconsideration Form - COB UnclearOpen a PDF
  • Request for Grievance or Appeal FormOpen a PDF
  • Member Care Management Program Referral FormOpen a PDF
  • UM Initial Determination Timeframes - Commercial ProductsOpen a PDF
  • UM Initial Determination Timeframes - Medicare ProductsOpen a PDF
  • UM Initial Determination Timeframes - Medicaid & Safety Net ProductsOpen a PDF
  • Court Ordered Treatment: Certification Form for Mental Health and Substance Use DisordersOpen a PDF
  • Physician's Order for Personal Care Services (DOH-4359)Open a PDF
  • Billing and Remittance
  • InstaMed Order FormOpen a PDF
  • APC Pricing Dispute FormOpen a PDF
  • APG Pricing Dispute FormOpen a PDF
  • Claim Adjustment or Retraction Request FormOpen a PDF
  • Dental Claim Research-Adjustment-Retraction Request FormOpen a PDF
  • Provider Remittance QuestionnaireOpen a PDF
  • Coordination of Benefits QuestionnaireOpen a PDF
  • DRG Review Request FormOpen a PDF
  • No-Fault, Workers Compensation and Medicare Exhausted Benefits FormOpen a PDF
  • Request for Timely Filing ReviewOpen a PDF
  • Overpayment Return FormOpen a PDF
  • Request for Out-of-Area Member Claim Appeal (BlueCard)Open a PDF
  • Analysis and Recovery Audit - Provider Request for Review FormOpen a PDF -
  • Brochures
  • Educational Resources Order FormOpen a PDF
  • Parent Package on 15 Adolescent TopicsOpen a PDF
  • Clinical Editing
  • Clinical Editing Review Request FormOpen a PDF
  • Clinical Editing Questions and AnswersOpen a PDF
  • Dental Claim Forms
  • Provider Submitted Dental Claim FormOpen a PDF
  • Provider Submitted Dental Claim Adjustment FormOpen a PDF
  • Customer Submitted Dental Claim FormOpen a PDF