Change Healthcare Notice

Forms

We’re simplifying our prior authorization forms and fax lines to make submissions easier. Two new forms--one for inpatient and one for outpatient requests--will replace authorization forms located within the Authorization/Extension Requests, Behavioral Health, and Medicare Advantage Forms sections below.

We’re also streamlining our fax lines to one dedicated number per line of business. Learn more.

Administrative

BlueCard Claim Appeal Form.
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.
Professional Provider Claims
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.
See More

Authorization/Extension Requests

NEW: Inpatient Authorization Request
NEW: Outpatient Authorization Request
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
See More

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
See More

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
See More

Institutional/Ancillary Credentialing

Facility Data Sheet
Request for Information (RFI) Application
List of Required Credentialing Documents
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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
See More

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
See More

PCMH Enrollment

Attachment A
Attachment B
Program Checklist
PCMH Change in Provider Information
Medical Panel Transfer Form
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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.

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Pharmacy Forms

Brand Exception Request Form
Rx Mail Order Form
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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
See More