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Provider Forms

Provider

Provider Change Form  
he Provider Change Form is used (facilities excluded) when service address, mailing address, billing address or tax ID number is changing. You must include the previous address or tax ID number and a term date. Entire form must be completed as failure to provide requested information could result in non-Network payments.

Additional Office Location Form
The Additional Office Location Form is used (facilities excluded) when a network provider wants to add another office location. This form can be used for a new or existing tax ID number. Always submit a W9 for a new tax ID number.

Facility

Facility Change Form
The Facility Change Form is used when service address, mailing address, billing address or tax ID number is changing. You must include the previous address or tax ID number and a term date. Entire form must be completed as failure to provide requested information could result in non-Network payments.

Facility Additional Location Form
The Facility Additional Office Location Form is used when a network facility provider wants to add another location. This form can be used for a new or existing tax ID number.  Always submit a W9 for a new tax ID number. 


Certification Request Forms

Use these forms to request certification of the specified medical care for your HealthChoice patients. Penalties are applicable for services that are not certified.

SilverScript Plan Members 
To request a Part D prior authorization, contact CVS/caremark toll-free at 1-855-344-0930.

Current employees, Pre-Medicare Former Employees and Without Part D Plan Members 
To request a prior authorization, contact CVS/caremark toll-free at 1-800-294-5979.


Certification Administrator Request Form
Use this form to certify diagnostic imaging services, specific outpatient surgeries and inpatient health care as specified in the Provider Network contracts and identified in the Provider Manual. Penalties are applicable for services that are not certified.