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View Forms and Documents
View Forms and Documents Top Page Content
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.
View Forms and Documents Accordion Content
- 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 FormOpen a PDF (for products listed on the form only)
- Prenatal Incentive Program Registration Form for Safety Net MembersOpen a PDF
- Applied Behavioral Analysis Provider Request FormOpen a PDF
- Children and Family Treatment & Support Services Intake FormOpen a PDF
- Children's Home and Community-Based Services Intake FormOpen a PDF
- Confirmation of Pregnancy Form - (includes Group Therapy Proposal Summary)Open a PDF
- Group Therapy Format Description FormOpen a PDF
- DBT Group Therapy Format Description Form - (includes Group Therapy Proposal Summary)Open a PDF
- 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
- 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
Prescription Drugs
Medical & Behavioral Health
- SafetyNet Fax Form for Inpatient Preauthorization RequestsOpen a PDF
- SafetyNet Fax Form for Outpatient Preauthorization RequestsOpen a PDF
- NeuroPsychological Testing Authorization Request FormOpen a PDF
- Outpatient Treatment Authorization Request FormOpen a PDF
- Adult Behavioral Health Home and Community Based Services (BH HCBS): Prior and/or Continuing Authorization Request FormOpen a PDF
