Update Your Provider Information (updated 2/11/2010)
Form used for provider or office changes. Such as: a new provider, a new locum tenens provider, a provider leaving, a new clinic location etc… We need your current information for our provider database to ensure that your claims are processed correctly and that you are eligible to print on our web site and in our directories.
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Criteria for Drugs Requiring Pre-Authorization (updated 10/2/2009)
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Pre-Service Authorization Form (updated 6/8/2009)
Use this form for Pre-Service Authorization
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Clinic Change Form (updated 4/22/2008)
Form used in our annual provider audit mailing to communicate clinic changes.
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W-9 Form (updated 4/22/2008)
If you have business changes that affect your 1099 status with the IRS, please send an updated W9 form.
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Provider Audit Form (updated 4/22/2008)
Form used in our annual provider audit mailing to send us your full list of active providers.
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Drug Pre-Service Authorization Form (updated 5/2/2007)
Drug Pre-Service Authorization Form
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