Change Healthcare Notice

Medical Forms

Authorization/Extension Requests

ABA Request for Authorization Form

Air Ambulance Authorization Form

Behavioral Health Request Authorization Form

Durable Medical Equipment Authorization

Home Care Authorization

Hospice Authorization

Infertility Pre-Treatment Form

Infusion Therapy Authorization

Outpatient Pre-Treatment Authorization Program (OPAP) Request

Precertification Request for Authorization of Services

Post-Acute Care Authorization Form

Continuity of Care - Members in a Maryland Based Plan (PDF)

Continuity of Care - Provider Not in Network (PDF)

Maryland Uniform Treatment Plan Form

Utilization Management Request for Authorization Form

NICU Precertification Form