Forms & Resources

Below are important forms and information:

• Appointment of Representative
• Non-Par Provider Appeal Form
• Waiver of Liability
• Online Provider Dispute Instructions
• PAR Provider Dispute Form
• Member transition of care form (English/Spanish)
• Member Care Information registration form
• My Care Information member authorization form (English/Spanish)
• Prior authorization form (see attached Prior Authorization List)
• Prescription Drug Mail Order Form (English & Español)
• Medicare Part D Prescription Claim Form (English & Español)
• Pharmacy Coverage Determination Form
• ERA Authorization Enrollment Form
• Wire Authorization Form
• EFT Authorization Enrollment Form
• Gender Affirming Services PA Form
• Getting Started in Connect Center
• Getting Started with Eligibility in ConnectCenter
• Getting Started with Provider Management in ConnectCenter
• Getting Started with Claims in ConnectCenter
• Uploading a Claim in ConnectCenter
• Keying Professional Claims in ConnectCenter
• Keying Institutional Claims in ConnectCenter
• Obtaining a Claim status in ConnectCenter