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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.
  • 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
  • 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