Forms

Member Forms

• Appointed Representative Form
• PHI Authorization Request
• Prior Authorization Request
• Member Reimbursement Form
• HMO Plus (HMO) Appeals and Grievances Form
• Premium Deduction Authorization
• Privacy Notice

< Return to Member's Section

Provider Forms

• ePower
• CMS 1450
• CMS 1500
• Provider Information Changes
• NC Uniform Credentialing Application
• Electronic Funds Transfer Request
• Electronic Remittance Advice Form
• Waiver of Liability Statement
• Health Risk Assessment Form
   
• Medical Management
  • Prior Authorization Request
  • Prior Authorization List

< Return to Provider's Section

Pharmacy Forms

• Best Available Evidence (www.cms.gov)
• Mail Order Drug Form
• Personal Medication Form
• Pharmacy Claim Reimbursement Form
  
• Medicare Part D Coverage Determination Requests
  • Part D Coverage Determination/Exception
    Part D Coverage Determination Request - Paper Form
  • Part D Redetermination (Appeal) – Web Form

< Return to Pharmacy Corner

Agent Forms

Marketing Event Reporting Form

Scope of Appointment

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