Forms

To make it easier to find the forms you use regularly, we’ve put them all in one place. Some forms can be submitted online, and others can be printed and then faxed or mailed to us. (There are specific instructions on each form.)

Become a Participating Provider 
Use this online form to apply for participation in our network.

Website Registration
To register as a participating provider and access our secure Provider site, you’ll need to request a provider personal identification number (PIN).

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Case Management Referral Form

Please complete this form to refer a member for case management services.

W-9

Form for providing taxpayer identification number and certification for federal reporting purposes.

CMS-1500 (08-05) Form Completion Informational Guide

This guide is designed to help you when completing the CMS-1500 (08-05) form.

Behavioral Health Provider Practice Information Survey

By taking part in this survey, you’re helping ensure that our members have the most up-to-date information about your practice.

Primary Care/Behavioral Health Communication Form

This form is designed to increase communication and provide care coordination between behavioral health and primary care providers.

Practitioner Change Form

Please use this form to notify us of any changes to your practice.