Forms

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

You may need to download Adobe Acrobat Reader to open these files.

Contracting and Practice Changes

• Navigate HAP Provider Change Form 
  Use this form to submit any changes for your practice and update your information.

Member-Related Forms

• Navigate Special Supplemental Benefits for the Chronically Ill (SSBCI) Provider Attestation Form 
  Submit this form to confirm your patient has been diagnosed with one or more qualifying conditions and meets the CMS criteria for receiving SSBCI.

Medical Prior Authorization

• Navigate Medical Prior Authorization Request Form

Claims

• Navigate Claim Recovery Refund Check Form
• Itemized Bill Cover Sheet (coming soon)
• Member Claim Form (coming soon)
• Navigate Optum Claims Review Process FAQ
• Navigate Overpayment Recovery Form

Fraud, Waste and Abuse

• Fraud, Waste and Abuse Reporting Form