Skip to main content

PROVIDER FORMS

Appointment of Representative (Group Members)

Appointment of Representative (Medicare Members)

AvMed Verification Form

Care Opportunity Response Form

Continuity of Care Authorization Form - Out of Network Providers

Coordination of Benefits Claim Form

Credentialing Application

CVS Specialty Drug List - January 2021

CVS Specialty Medication Delivery Program Form

CVS Specialty Referral Form

Directory Information Change Form

EMI Ophthalmology CPT Code List

Hospital Admission Emergent Urgent Direct Admissions Form

Hospital Resource Form

Instruction on Billing Additional Codes

Medical Oncology & Hematology Prior Authorization Matrix

Medical Prior Authorization Request Form

Medication Exception Request Form (Commercial)

Medication Exception Request Form (Medicare)

Member Transition of Service Form – Medical and Pharmacy

NCH Cardiology FAQs

NCH Cardiology Matrix

NIA-RadMD Benefits

NIA-RadMD Imaging Provider Handbook

NIA-RadMD Quick start Guide

No Authorization Required List Of Procedure Codes

Notice of Medicare Non-Coverage Form

Notice of Medicare Non-Coverage Form (Spanish)

NPI Provider Notification Form

On Call Relationship

PCP-Behavioral Health Coordination Form

Provider Interest Form

Request for Claim Review / Appeal

Request for Claim Status

Request to Reopen a Medicare Adverse Determination

Specialty Medication Dis-Enrollment Form

Standard Notice and Consent Documents Under the No Surprises Act

Waiver of Liability for AvMed Medicare Non-Participating Providers