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Behavioral Health Forms

PATIENT CARE FORMS

Diabetic Retinal Exam Referral Form
Use this form when completing Diabetic Retinal Exam Referrals
Durable Medical Equipment Preauthorization Form
Health Care Proxy Form
The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.
Health Survey for Adolescents
A brief tool to help address high priority risk behaviors and allow for dialogue between the adolescent and their health care provider.
Health Survey for Adolescents Provider Information
Health Survey for Adolescents Provider Information
Injectable Medication Prior Approval Medical Necessity Form
This prior authorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services. *Not to be used for Synvisc or Orthovisc injections. Please use Preauthorization Form: Outpatient Services (below).
In-Network Referral Form
Fillable form for fax use.
Health Care Services Referral Form
Lead Poisoning Home Checklist
Lead Risk Assessment
In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age.
Obstetrics/Gynecology Examination Report
Obstetrics/Gynecology Examination Report
Out of Plan Referral Review Request Form
This form is used to request an Out-of-Plan Referral also referred to as an Out-of-Network Referral, for services outside of the Servicing Network.
Home Health Care Preauthorization Form
Preauthorization Form: Outpatient Services
Preauthorization Form: Transplant
Preauthorization / Non Formulary Drug Request Form
This preauthorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services.
Radiology UM Guide Nuclear Cardiology Addendum
Radiology UM Guide Nuclear Cardiology Addendum
Med D Coverage Determination Form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.

PRACTICE ADMINISTRATION

Reimbursement Forms

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