Forms (138 rows returned) List
| | | » | Forms (138 rows returned) |
| |
|
| Access to Initial Application Letters | PDF | PROVIDER ENROLLMENT | 298.5 | 01/15/2020 | |
| Appendix FF - Notice of Intent to Become a CCSP Service Provider | PDF | PROVIDER ENROLLMENT | 290.3 | 05/04/2021 | |
| Appendix HH - CCSP Application Checklist | PDF | PROVIDER ENROLLMENT | 250.9 | 02/16/2018 | |
| Authorization and Release of Information Form | PDF | PROVIDER ENROLLMENT | 156.6 | 09/03/2019 | |
| Catamaran 835 Payment Advice Request Form | PDF | PHARMACY | 24.7 | 01/16/2013 | |
| CCSP & Source Standard Assurances Form | PDF | PROVIDER ENROLLMENT | 62.8 | 02/03/2020 | |
| Certification of Medical Necessity for Apnea/Bradycardia Monitor | PDF | PRIOR AUTHORIZATION | 282.9 | 01/08/2019 | |
| Certification of Medical Necessity for Continuous Glucose Monitor | PDF | PRIOR AUTHORIZATION | 123.2 | 10/01/2019 | |
| Certification of Medical Necessity for Continuous Positive Airway Pressure (CPAP) Device | PDF | PRIOR AUTHORIZATION | 286.4 | 01/08/2019 | |
| Certification of Medical Necessity for Custom Durable Medical Equipment | PDF | PRIOR AUTHORIZATION | 303 | 01/08/2019 | |
| Certification of Medical Necessity for Enternal Nutrition Therapy for Members Under 21 Years of Age | PDF | PRIOR AUTHORIZATION | 287.8 | 01/08/2019 | |
| Certification of Medical Necessity for External Infusion Pump | PDF | PRIOR AUTHORIZATION | 317 | 01/08/2019 | |
| Certification of Medical Necessity for Group I Pressure Reducing Support Surface | PDF | PRIOR AUTHORIZATION | 280.9 | 01/08/2019 | |
| Certification of Medical Necessity for Hospital Bed | PDF | PRIOR AUTHORIZATION | 271.8 | 01/08/2019 | |
| Certification of Medical Necessity for Insulin Infusion Pump | PDF | PRIOR AUTHORIZATION | 350.9 | 01/08/2019 | |
| Certification of Medical Necessity for Intermittent Assist Device (BIPAP) | PDF | PRIOR AUTHORIZATION | 323.1 | 01/08/2019 | |
| Certification of Medical Necessity for Manual Wheelchair | PDF | PRIOR AUTHORIZATION | 290.9 | 01/08/2019 | |
| Certification of Medical Necessity for Oxygen Equipment | PDF | PRIOR AUTHORIZATION | 272.2 | 01/08/2019 | |
| Certification of Medical Necessity for Patient Lift | PDF | PRIOR AUTHORIZATION | 282.4 | 01/08/2019 | |
| Certification of Medical Necessity for Power Wheelchair | PDF | PRIOR AUTHORIZATION | 314.8 | 01/08/2019 | |
| Certification of Medical Necessity for Respiratory Suction Pump | PDF | PRIOR AUTHORIZATION | 266.4 | 01/08/2019 | |
| Certification of Medical Necessity for Scooter/Power Operated Vehicle (POV) | PDF | PRIOR AUTHORIZATION | 288.3 | 01/08/2019 | |
| Certification of Medical Necessity for Speech Generating Devices and Mobile Devices used as a Speech Generating Device with AAC Therapy Application or Software | PDF | PRIOR AUTHORIZATION | 276.5 | 01/08/2019 | |
| Certification of Medical Necessity for Transcutaneous Electrical Nerve Stimulator (Tens Unit) | PDF | PRIOR AUTHORIZATION | 271.8 | 01/08/2019 | |
| Certification of Medical Necessity for Ventilators | PDF | PRIOR AUTHORIZATION | 107.4 | 03/29/2019 | |
| Claim Attachment Coversheet | PDF | CLAIMS | 70.6 | 06/06/2019 | |
| Clinical Viewer Policy | PDF | GAHIN AGREEMENT | 471.7 | 07/28/2016 | |
| CVO Required Documents Checklist | PDF | PROVIDER ENROLLMENT | 75.9 | 05/31/2017 | |
| DCH Amended BAA with Truven for Member Affiliates | PDF | GAHIN AGREEMENT | 252.7 | 07/28/2016 | |
| DCH Clinical Viewer Breach Report | PDF | GAHIN AGREEMENT | 273 | 07/28/2016 | |
| DCH Medicaid Provider User Agreement | PDF | GAHIN AGREEMENT | 391.7 | 07/28/2016 | |
| DCH Member Affiliate Agreement | PDF | GAHIN AGREEMENT | 336.4 | 07/28/2016 | |
| Delegated Credentialing Entity Attestation Form | PDF | PROVIDER ENROLLMENT | 91.8 | 03/22/2018 | |
| Dental Claim Form | PDF | CLAIMS | 57.1 | 10/27/2010 | |
| Disclosure of Ownership and Control Interest Statement - Contractors Only | PDF | PROVIDER ENROLLMENT | 648.9 | 04/09/2019 | |
| Disclosure of Ownership and Control Interest Statement - Contractors Only-NEMT | PDF | PROVIDER ENROLLMENT | 635.7 | 04/09/2019 | |
| Disclosure of Ownership and Control Interest Statement - Providers Only | PDF | PROVIDER ENROLLMENT | 611.6 | 04/09/2019 | |
| Disclosure of Ownership and Control Interest Statement - Trading Partners Only | PDF | PROVIDER ENROLLMENT | 630.8 | 04/09/2019 | |
| DMA-276: Hysterectomy Form | PDF | ALL CATEGORIES | 218.9 | 05/21/2015 | |
| DMA-285: Third Party Liability Questionnaire | PDF | CLAIMS | 20.7 | 10/27/2010 | |
| DMA-292: Request for Forms or Handbooks | PDF | ALL CATEGORIES | 223.1 | 03/10/2011 | |
| DMA-311: Certificate of Necessity for Abortion | PDF | PRIOR AUTHORIZATION | 306.1 | 07/24/2015 | |
| DMA-312: COB/TPL Accident Information Report | PDF | PRIOR AUTHORIZATION | 220.5 | 09/21/2015 | |
| DMA-322: Exceptional Transport PA Request | PDF | PRIOR AUTHORIZATION | 180.9 | 02/01/2020 | |
| DMA-400: Medically Needy First Day | PDF | CLAIMS | 78.6 | 10/27/2010 | |
| DMA-410: COB Notification Form | PDF | CLAIMS | 156.6 | 10/05/2018 | |
| DMA-460: Medicare Notification Form | PDF | CLAIMS | 97.6 | 10/27/2010 | |
| DMA-501: Claims Adjustment Request | PDF | CLAIMS | 108.5 | 04/19/2019 | |
| DMA-521: Hospice Referral Form for Non-Hospice Related Svcs. | PDF | PRIOR AUTHORIZATION | 58.9 | 10/27/2010 | |
| DMA-521A: Hospice Referral Form | PDF | ALL CATEGORIES | 30.5 | 10/30/2017 | |
|