We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.
Request Forms
Coordination of Care and Release of Information Form (coming soon)Use this form to share patient care information with another provider.
Primary Care Manager (PCM) Change Request FormUse this form to submit a PCM change request.Medical Prior Authorization Forms
Medical Prior Authorization Request FormSubmit this form to request medical prior authorization.
Nursing Facility Form (coming soon)Submit this form to request prior authorization for a nursing facility admission.
Outpatient Mental Health Prior Authorization Form (coming soon)Submit this form to request prior authorization for outpatient mental health services.
Urine Drug Screen Prior Authorization Form (coming soon)Submit this form to request prior authorization for urine drug screening for patients with a substance use disorder.
SUD 1115 Waiver Universal Prior Authorization Form (coming soon)Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization Substance Use Disorder (SUD) services.
Claims Forms
Claim Refund Check FormMail your refund check, this form and any other required documentation to TRICARE Prime Demo.
CMS 1500 Health Insurance Claim Form (coming soon)Waiver services providers who cannot log into the provider portal can use this form to submit a claim. Access instructions to complete the form and a list of valid service codes.
ECHO Health Enrollment (coming soon)Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
Itemized Bill Cover SheetSubmit this cover sheet and itemized statement for high dollar claims.Overpayment Recovery FormProviders may submit Recovery Requests via the provider portal.Provider Standard Claim Dispute FormSubmit this form to dispute a standard claim. The best way to submit is via the provider portal. It can also be mailed to the address on the bottom of the form.Appeals Forms
Appointment of Representation (AOR) Form (coming soon)Submit this form if you are not a physician or a physician representative.
Consent for Provider to File an Appeal on Patient/Beneficiary’s BehalfSubmit this form to request an appeal on behalf of a beneficiary.Provider Appeal Request FormSubmit this form to request an appeal for an authorization, post-service, contract or other issue.Expedited Provider Appeal Request FormWaiver of Liability Form for Claim Appeals (coming soon)Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.
Dental Forms
ADA Dental Claim Form Instructions (coming soon)Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.
Dental EFT Enrollment Authorization Agreement Form (coming soon)Follow the instructions to enroll in Scion Dental’s EFT program.
ODJFS Dental Services Prior Authorization Form (coming soon)Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.
TMD Screening Examination Form (coming soon)Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.
Fraud, Waste and Abuse
Fraud, Waste and Abuse Reporting Form (coming soon)Submit this form to report suspected fraud, waste or abuse.
Prior Authorization
Utilization Management Prior Authorization Form (coming soon)Submit this form to request prior authorization from Utilization Management for medical and mental health services (such as inpatient admission or home health care) or for durable medical equipment.
Pharmacy Prior Authorization (Medical Benefit) Prior Authorization FormSubmit this form to request a prior authorization to prescribe provider administered drugs covered and reimbursable by CSMV under the medical benefit.