Provider Forms
Click on a category to "jump" to the form(s) you need!
Behavioral Health Forms | Change Forms | Credentialing Forms
easyLink for Providers Forms | Pharmacy Forms|
Radiology Forms
| Total Hip Replacement Review Tool
Total Knee Arthoplasty (TKA) Forms | Transportation Request Forms
Plantar Fascial Release Forms | Septoplasty Forms
Behavioral Health Forms
Form |
Description |
| 1 |
Mental Health Outpatient Treatment Report |
Request for additional mental health visits |
| 2 |
Preferred Care Outpatient Chemical Dependency Treatment Summary |
Request for additional chemical dependency visits |
| 3 |
Timothy's Law request form |
Timothy's Law request form |
Back to Top
Change Forms
Back to Top
Credentialing Forms
| Form |
Description |
| 1 |
Federal
Tax W-9 |
For use by providers who are establishing a
new individual or group practice. The IRS requires Preferred Care to have
a completed W-9 on file for each new individual, group or facility contract. |
| 1a |
Reasonable Cause Regulations and Requirements for Missing and Incorrect Name/TINs |
Refer to Section VIII in this excerpt from IRS publication 1586, which offers clarification on how to fill out the W-9 Form, and includes instructions for reading magnetic tape. |
| 2 |
CAQH Provider Data Form |
To begin the credentialing process through the CAQH Universal Credentialing DataSource®, please use this simple, standardized form.
|
| 3 |
Nurse Practitioner/Physician Assistant Registration Form |
After completing and signing the form, please attach a copy of your
license, DEA certificate, and malpractice insurance and send to:
Preferred Care
Network Management Dept.
259 Monroe Avenue
Rochester, New York 14607
or fax to:(585) 327-2289 |
Back to Top
Preferred Care easyLinksm for Providers Forms
Form |
Description |
| 1 |
Provider Access Information Form and User Validation Information Form |
To make downloading and form completion easier, we have combined all forms in one easy to download document.
- Use the Provider Access Information Form to identify all Provider / Office Staff who will need electronic Preferred Care access.
- Use the User Validation form to request a passcode and activate your electronic Preferred Care account. (This form is essential for logging in to easyLink)
|
Back to Top
Pharmacy Forms
Form |
Description |
| 1 |
Drug Prior Justification Form |
Refer to the Preferred Care Pharmacy Management Administrative Policy for details. |
Back to Top
Plantar Fascial Release Forms
Form |
Description |
| 1 |
Plantar Fascial Release
Review Tool |
As of October 1, 2007 Preferred Care requires the provider to submit clinical findings that support Plantar Fascial Release Surgery. This form outlines the clinical and administrative information required for an outpatient authorization for Plantar Fascial Release. |
Back to Top
Radiology Forms
Form |
Description |
| 1 |
Radiology Review Tool |
To obtain Prior Justification for Imaging Studies, ordering providers may elect to complete this review tool. |
Back to Top
Total Hip Replacement Review Tool
Form |
Description |
| 1 |
Total Hip Replacement Review Tool |
For surgeries scheduled on or after January 27th, 2008, Preferred Care will require prior authorization for total hip arthroplasty (THA), for all products except Preferred Care Gold (Medicare). This form outlines the clinical and administrative information required for an inpatient authorization for THA.
|
Back to Top
Total Knee Arthoplasty (TKA) Forms
Form |
Description |
| 1 |
Total Knee Joint Replacement
Review Tool |
As of July 1, 2007, Preferred Care requires the provider to submit clinical findings that support the TKA. This form outlines the clinical and administrative information required for an inpatient authorization for TKA.
|
Back to Top
Transportation Request Forms
Back to Top
Septoplasty Forms
Form |
Description |
| 1 |
Septoplasty Review Tool |
For septoplasties scheduled on or after October 1, 2007 Preferred Care requires the provider to submit clinical findings that support the septoplasty. The form outlines the clinical and administrative information required for an outpatient authorization for a septoplasty. |
Last updated: August 28, 2007
|
Need
help choosing a health plan?
