Forms

Administrative

Change in Provider Information - Institutional/Ancillary

Please submit letterhead with this form.

Change in Provider Information – Professional

Please submit letterhead with this form.

D.C. Minor Vaccination Consent Notification Form.

Hospital Attestation for Patient Safety Initiatives

Institutional Provider Claims

Important information on the CMS Website.

Provider Inquiry Resolution Form

Do not use this form for Appeals or Corrected Claims. This form is to be used for Inquiries only.

Provider Refund Submission Form

Uniform Consultation Referral Form

The editable version of this form is available by logging into the Provider Portal.

Authorization/Extension Requests

ABA Request for Authorization Form

Air Ambulance Authorization Form

Behavioral Health Inpatient Authorization Form

Behavioral Health Inpatient Concurrent Review Request Form

Behavioral Health Outpatient 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

Behavioral Health

Behavioral Health Inpatient Authorization Form

Behavioral Health Inpatient Concurrent Review Request Form

Behavioral Health Outpatient Authorization Form

District of Columbia Treatment Plan Form

Maryland Uniform Treatment Plan Form

Dental Credentialing

Dental Billing Authorization Form

Dental Practice Questionnaire

Dental Provider Application

Dental Provider Application Instructions

Required Documents for Dental Credentialing

CAQH ProView Data Sheet

Institutional/Ancillary Credentialing

Facility Data Sheet

Request for Information (RFI) Application

List of Required Credentialing Documents

Medicare Advantage Forms

Medicare Advantage DME Prosthetics and Orthotics Authorization Request Form

Medicare Advantage Home Care Authorization Form

Medicare Advantage Outpatient Pre-Treatment Authorization Program (OPAP) Request Form

Medicare Advantage Post-Acute Transitions of Care Authorization Form

Medicare Advantage Prior Authorization Form - Utilization Management

Medicare Advantage Continuity of Care Form

PCMH Member

Enhanced Monitoring Member Service Request Form - No Care Plan Required

Enhanced Monitoring Member Consent Form - No Care Plan Required

Election to Participate Form

Election to Participate Form - Large Print

Election to Participate Form

- Spanish version

Election to Participate Form

- Korean version

Revocation of Election to Participate

Revocation of Election to Participate

- Spanish version

Revocation of Election to Participate

- Korean version

PCMH Enrollment

PCMH Change in Provider Information

Medical Panel Transfer Form

Pharmacy Prior Authorization

Prior authorization requests for drugs should be requested electronically through the CareFirst Provider Portal.

Drug Policies and additional information is available on the Pharmacy Prior Authorization page.

Pharmacy Forms

Brand Exception Request Form

Rx Mail Order Form

Independent Review Entity Forms

Medicare Managed Care Dismissal Case File Data Form

New Reconsideration Case File Transmittal Cover Sheet

Reconsideration Background Data Form

Reopening Request Form

New Reconsideration Case File Transmittal Cover Sheet

Statement of Compliance Form

Statement of Compliance ALJ Form