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  Monday, December 10, 2018
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Forms (137 rows returned) List
 
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Forms (137 rows returned)

 
 TitleFile TypeCategorySize (KB)Release Date 
Appendix FF - Notice of Intent to Become a CCSP Service ProviderPDFPROVIDER ENROLLMENT315.102/16/2018 
Appendix HH - CCSP Application ChecklistPDFPROVIDER ENROLLMENT250.902/16/2018 
Attestation Form for Specialty Provider for Autism ServicesPDFPROVIDER ENROLLMENT252.403/22/2018 
Authorization and Release of Information FormPDFPROVIDER ENROLLMENT207.605/31/2017 
Catamaran 835 Payment Advice Request FormPDFPHARMACY24.701/16/2013 
CCSP Standard Assurance DocumentationPDFPROVIDER ENROLLMENT129.202/16/2018 
Certification of Medical Necessity for Apnea/Bradycardia MonitorPDFPRIOR AUTHORIZATION27910/15/2018 
Certification of Medical Necessity for Continuous Glucose MonitorPDFPRIOR AUTHORIZATION284.610/15/2018 
Certification of Medical Necessity for Continuous Pressure Airway DevicePDFPRIOR AUTHORIZATION294.510/15/2018 
Certification of Medical Necessity for Custom Durable Medical EquipmentPDFPRIOR AUTHORIZATION313.610/15/2018 
Certification of Medical Necessity for Enternal Nutrition Therapy for Members Under 21 Years of AgePDFPRIOR AUTHORIZATION296.810/15/2018 
Certification of Medical Necessity for External Infusion PumpPDFPRIOR AUTHORIZATION312.510/15/2018 
Certification of Medical Necessity for Full Volume VentilatorPDFPRIOR AUTHORIZATION283.410/15/2018 
Certification of Medical Necessity for Group I Pressure Reducing Support SurfacePDFPRIOR AUTHORIZATION277.610/15/2018 
Certification of Medical Necessity for Hospital BedPDFPRIOR AUTHORIZATION281.510/15/2018 
Certification of Medical Necessity for Insulin Infusion PumpPDFPRIOR AUTHORIZATION360.510/15/2018 
Certification of Medical Necessity for Intermittent Assist Device (BIPAP)PDFPRIOR AUTHORIZATION331.610/15/2018 
Certification of Medical Necessity for Manual Wheelchair PDFPRIOR AUTHORIZATION299.810/15/2018 
Certification of Medical Necessity for Oxygen EquipmentPDFPRIOR AUTHORIZATION280.710/15/2018 
Certification of Medical Necessity for Patient LiftPDFPRIOR AUTHORIZATION269.410/15/2018 
Certification of Medical Necessity for Power Wheelchair PDFPRIOR AUTHORIZATION302.510/15/2018 
Certification of Medical Necessity for Respiratory Suction PumpPDFPRIOR AUTHORIZATION276.610/15/2018 
Certification of Medical Necessity for Scooter/Power Operated Vehicle (POV) PDFPRIOR AUTHORIZATION272.210/15/2018 
Certification of Medical Necessity for Speech Generating Devices and Mobile Devices used as a Speech Generating Device with AAC Therapy Application or SoftwarePDFPRIOR AUTHORIZATION283.410/15/2018 
Certification of Medical Necessity for Transcutaneous Electrical Nerve Stimulator (Tens Unit)PDFPRIOR AUTHORIZATION280.510/15/2018 
Claim Attachment CoversheetPDFCLAIMS65.405/26/2017 
Clinical Viewer PolicyPDFGAHIN AGREEMENT471.707/28/2016 
CVO Required Documents ChecklistPDFPROVIDER ENROLLMENT75.905/31/2017 
DCH Amended BAA with Truven for Member AffiliatesPDFGAHIN AGREEMENT252.707/28/2016 
DCH Clinical Viewer Breach ReportPDFGAHIN AGREEMENT27307/28/2016 
DCH Medicaid Provider User AgreementPDFGAHIN AGREEMENT391.707/28/2016 
DCH Member Affiliate AgreementPDFGAHIN AGREEMENT336.407/28/2016 
Delegated Credentialing Entity Attestation FormPDFPROVIDER ENROLLMENT91.803/22/2018 
Dental Claim FormPDFCLAIMS57.110/27/2010 
Disclosure of Ownership Control Interest Statement Contractors OnlyPDFPROVIDER ENROLLMENT634.509/26/2018 
Disclosure of Ownership Provider OnlyPDFPROVIDER ENROLLMENT202.705/13/2015 
Disclosure of Ownership Trading Partners OnlyPDFPROVIDER ENROLLMENT694.609/26/2018 
DMA-276: Hysterectomy FormPDFALL CATEGORIES218.905/21/2015 
DMA-285: Third Party Liability QuestionnairePDFCLAIMS20.710/27/2010 
DMA-292: Request for Forms or HandbooksPDFALL CATEGORIES223.103/10/2011 
DMA-311: Certificate of Necessity for AbortionPDFPRIOR AUTHORIZATION306.107/24/2015 
DMA-312: COB/TPL Accident Information ReportPDFPRIOR AUTHORIZATION220.509/21/2015 
DMA-322: Exceptional Transport PA RequestPDFPRIOR AUTHORIZATION77.711/12/2010 
DMA-400: Medically Needy First DayPDFCLAIMS78.610/27/2010 
DMA-410: COB Notification FormPDFCLAIMS156.610/05/2018 
DMA-460: Medicare Notification FormPDFCLAIMS97.610/27/2010 
DMA-501: Claims Adjustment RequestPDFCLAIMS166.603/28/2016 
DMA-521: Hospice Referral Form for Non-Hospice Related Svcs.PDFPRIOR AUTHORIZATION58.910/27/2010 
DMA-521A: Hospice Referral FormPDFALL CATEGORIES30.510/30/2017 
DMA-526: Physician''s Statement for EMAPDFALL CATEGORIES12.910/20/2010 
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