Provider Self-Help Forms

Facility/Practitioner Notification Forms
New Practitioner Form Practitioner Termination Form New Location Form	Location Termination Form Change Form

Medical Management
Prior Authorization Request Form Instructions for Completing the Prior Authorization Form	Complex Case Management Form Guideline to Review for Authorization of Varicose Vein Treatment

Health Services

Claims

Electronic Remittance Advice (ERA/835) & Electronic Funds Transfer (EFT)

Pharmacy

Behavioral Health Forms
UWBH Treatment Plan Instructions UWBH Outpatient Treatment Plan Request Behavioral Health Communication Form	UWBH Outpatient Treatment Psychiatrist Form UWBH Authorization Addition Extension Form