Provider Forms & Resources
Provider Partners
FORMS
- Provider Addition Form
- Provider Termination Form
- Provider Demographic Change Form
- Provider Contact Form
- Medical Prior Authorization Form
- Pharmacy Pre-Authorization Form
- Optum Rx Pharmacy Pre-Authorization Form
- Claim and Authorization Reconsideration Form
- Over-Under Large Claim Adjustment Form
- Prescription Drug Appeal From – Hometown Health
- Request for Redetermination of a Medicare Prescription Drug Denial – Senior Care Plus
