Forms & Resources

Resources

  • Specialist Roster (updated 11/16/2017): Excel
  • Ancillary Roster (updated 11/16/2017): Excel

General Forms

  • Treatment Authorization (TAR) Form (Revised 4/2014): Word | PDF
  • Provider Portal Access Request Form (Revised 3/2015): PDF

Claims Dispute Forms

  • Provider Dispute Resolution Request (PDRR) Form: Word | PDF
  • Provider Dispute Resolution Request (PDRR) Instructions: Word | PDF

Other Forms

  • None