
Facility/Practitioner Notification Forms
New Practitioner Form
Practitioner Termination Form
New Location Form
Location Termination Form
Change Form
Medical Management
Prior Authorization Request Form ![]()
Complex Case Management Form ![]()
Health Services
9 Months & More Enrollment Form ![]()
Claims
Claim Adjustment Form ![]()
Pharmacy
MedWatch Form ![]()
Prior Authorization/Formulary Exception Request Form (Pharmacy) ![]()
Specialty Mail Service Pharmacy Enrollment Form ![]()
Behavioral Health Treatment Forms
UWBH Treatment Plan Instructions ![]()
UWBH Outpatient Treatment Plan Request ![]()
UWBH Outpatient Treatment Psychiatrist Form ![]()
UWBH Authorization Addition Extension Form ![]()