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Behavioral Health Forms


Diabetic Retinal Exam Referral Form
Durable Medical Equipment Preauthorization Form
This form is used to request a Prior Authorization for Durable Medical Equipment (DME)
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
In-Network Referral Form
Fillable form for fax use.
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.
Medicaid Managed Care Only Home Assessment PCS
This form must be completed for Medicaid patients receiving personal care services or requesting personal care services.
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.
NYS Medicaid Prior Authorization Form for Prescriptions
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.
Preauthorization Form: Outpatient Services
Preauthorization Form: Transplant
Home Health Care Preauthorization Form
Preconception Checklist
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.
Provider Office Accident Questionnaire
This form is used to assist in determining if a patient is eligible to receive Workers' Compensation, No-Fault Automobile or Personal Liability insurance benefits due to a possible accident or injury.


Reimbursement Forms

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