Forms & Resources

Below are important forms and information:

• Appointment of Representative
• Universal Roster
• Non-Par Provider Appeal Form
• Waiver of Liability
• Online Provider Dispute Instructions
• PAR Provider Dispute Form
• Member transition of care form (English/Spanish) (updated 4/6/2021)
• Member Care Information registration form
• My Care Information member authorization form (English/Spanish) (updated 4/6/2021)
• Prior authorization form (see attached Prior Authorization List)
• Prior Authorization Service File
• Aetna Clinical Policy Bulletin Link
• Prescription Drug Mail Order Form (English & Español)
• Medicare Part D Prescription Claim Form (English & Español)
• Provider Pharmacy Coverage Determination Form (updated 4/14/2021)
• Wire Authorization Form
• Gender Affirming Services PA Form
• Adult Day-Service Monthly Service Report
• Homemaker Healthy Home Montlhy Service Report