Medical Forms

The forms center contains tools that may be necessary for filing certain claims, appealing claims and changing information about your office.
Document Title Document Type Document Size Last Updated
Medical Forms
CALAP - Request-Refuse Interpretation Services - English PDF 405 KB 09/13/2013
CALAP - Request-Refuse Interpretation Services - Spanish PDF 24 KB 09/13/2013
CALAP - Request-Refuse Interpretation Services - Chinese PDF 97 KB 09/13/2013
CMS-1500 (HCFA1500) Online Resource -- 02/03/2015
Health Care Professional Dispute Resolution Request - CA HMO PDF 60KB 02/05/2015
Medical-Network Adequacy Provision Exception Form PDF 300kB 11/10/2021
Out-of-Network Disclosure Form – Referral to a non-participating provider Online Resource -- 03/21/2019
Physician Referral Form Online Resource -- 03/06/2017
Precertification Form Cervical Fusion or Cervical Disc Replacement PDF 292kB 03/01/2022
Precertification Form Lumbar Fusion PDF 300kB 03/01/2022
Prior Authorization Fax Form PDF 171KB 12/29/2021
Request for Health Professional Payment Review PDF 75KB 02/05/2015
Request for Health Professional Payment Review - Member PDF 656KB 02/26/2015
Submit a Referral to Cigna for Specialty Care PDF 47 KB 02/09/2021
UB-04 Online Resource -- 02/03/2015
Document Title Document Type Document Size Last Updated
State Forms
Arizona Standard Prior Authorization Form Online Resource -- 03/17/2022
Florida Medical Prior Authorization Form Online Resource -- 03/17/2022
Indiana Prior Authorization Form Online Resource -- 04/01/2016
Massachusetts Cardiac Imaging Prior Authorization Form PDF 47KB 12/17/2019
Massachusetts CT/CTA/MRI/MRA Prior Authorization Form PDF 52KB 12/17/2019
Massachusetts PET/PET CT Prior Authorization Form PDF 33KB 12/17/2019
New Mexico Prior Authorization Form Online Resource -- 08/20/2021
Texas Out-of-Network Referral Disclosure Form Online Resource -- 03/21/2019
Texas Standard Prior Authorization Request Form for Health Care Services Online Resource -- 08/04/2015
Vermont Gold Carding Pilot Program PDF 148kB 03/17/2022
Vermont Medical Prior Authorization Form Online Resource -- 12/24/2015
West Virginia Prior Authorization Form Online Resource -- 11/20/2019
Document Title Document Type Document Size Last Updated
Wellness Forms
Wellness Screening Form PDF 730KB 09/03/2021
Wellness Screening Form (Spanish) PDF 291KB 09/03/2021
Activity-Based Physician-Recommended Alternative and Waiver (Form A) PDF 318KB 09/03/2021
Activity-Based Physician-Recommended Alternative and Waiver (Form A) Spanish PDF 210KB 09/03/2021
Outcomes-Based Physician- Recommended Alternative and Waiver (Form B) PDF 275KB 09/03/2021
Outcomes-Based Physician- Recommended Alternative and Waiver (Form B) Spanish PDF 225KB 09/03/2021