Provider Forms

Category	Forms
Administrative	Practitioner Incentive Model (PIM) Form PIM 2012 FAQ for Practitioners	Patient Acceptance Form
Billing & Claims	Coding Review Request	Electronic Claim Submission Set-up (more information) Electronic Claims Request Form Problem Claims/ Refund Submission Form (PDF)	Timely Filing Waiver Request
Credentialing	Credentialing Application (for MD, DO, DDS, DPM) Credentialing Application (for AODA, AUD, DC, MH, OT, PhD, PsyD, PT, SLP) Credentialing Application (for APNP, CNM)	Credentialing Application (for LT, Hosptialists) Physician Extender (for PA, CRNA)	Organizational Application (for ASC, BH, HC, HHA, HO, SNF)
Patient	2011 Inpatient Elective Surgery List	Health Information Release (PHI) Home Health & Hospice Authorization Request Form Skilled Nursing Facility or Swingbed Authorization Form	Prior Authorization Form DME Authorization Request Form
Patient	Patient Satisfaction Survey Reminder 1 Patient Satisfaction Survey Reminder 2 Patient Satisfaction Survey Reminder 3 Preventive Service Reminder Template (Established Patients) Screening Recommendations Template (Established Patients)		Prior Authorization Form DME Authorization Request Form
Pharmacy	Drug Prior Authorization	Provider Exception	Expense Reimbursement