Forms and Documents

Advance directives

• Visit Caringinfo.org for your state's advance directive instructions and forms

Let Us Know (Rapid Response and Outreach Team)

• Rapid Response and Outreach Team Member Intervention Form (PDF)

Maternity

• Delivery Notification Form (PDF)
• Pregnancy Medical Home Risk Screening Form (PDF)

Medical authorizations

• Behaviorial Health Prior Authorization Form (PDF)
• Physical Health Prior Authorization Form (PDF)

Pharmacy prior authorizations

• Healthcare Common Procedure Coding System (HCPCS) Authorization Form (PDF)
• Pharmacy Prior Authorization Form (PDF)

Provider

• Member Consent for Provider/Representative to File an Appeal form (PDF)
• Provider Roster Template (xlsx) Submit completed roster to: ProviderEnrollmentNCEX@amerihealthcaritas.com
• Facility Roster Template (xlsx) Submit completed roster to: ProviderEnrollmentNCEX@amerihealthcaritas.com
• Provider Change form (PDF)
• Provider Claim Dispute Form (PDF)