Provider forms

Find whatever form you need in our fully-downloadable provider forms library.

Claims Requirements and Communications

Claims Submission Toolkit

Facility Payer ID Provider Number Reference

Implant Reimbursement Request Form

LTAC precertification form

Overpayment/Refund Form

Post-Acute Facility Admission Guide

Professional Payer ID Provider Number Reference

Request to Update Procedure Code(s) on an Existing Authorization

UB-04 Claim Form and Instructions

Waiver of Liability Statement

Claims Appeals

Emergency Room Review Form

Health Care Provider Application to Appeal a Claims Determination

Medicare Non-Contracted Provider Payment Dispute Process

Medicare Provider Appeal Process for Non-Contracted Providers

Out-of-Network Provider Claim Negotiation Form

Payment Dispute Decision (PDD) Request Form

Peer-to-Peer Request Form

Consent to Appeals of UM Determinations and Medical Release

HIPAA

HIPAA Authorization for Disclosure of Health Information

HIPAA Personal Representative Request Form

Policies

AIM Preauthorization/ RQI Request Fax Form

Other

Clinician Collaboration Form