Forms and References

Medicare Assured^® > Ohio > Providers > Forms and References

Providers Enroll as a Provider Ohio Medicare Assured^® Contact Us

BEHAVIORIAL HEALTH FORMS - these forms can be downloaded from http://www.cbhnp.org/gateprovforms.aspx
1	Outpatient Treatment Registration Form For Mental Health Services
2	Outpatient Treatment Registration Form For Substance Abuse
3	Request for Neuropsychological Evaluation
4	Request for Authorization of Psychological Testing
5	Mental Health & Substance Abuse Outpatient Form Instructions
PHARMACY FORMS
6	Medicare Assured^® Drug Exception Form
7	Smoking Cessation Form
8	Member Medicare Assured^® Drug Exception Form
9	Home Infusion Drug Request Form
10	Pharmacy NCPDP Payer Sheet
11	Medicare Part D Coverage Determination Request Form
GENERAL PROVIDER FORMS
12	Appointment of Representative Form
13	Asthma and Cardiac Referral Fax Form
14	CMS UB-04 Form
15	CMS-1500 Form
16	Maternity Outomes Authorization Form
17	Member Outreach Form
18	Notice of Discharge & Medicare Appeal Rights
19	Notice of Medicare Non-Coverage Form - Instructions
20	Obstetrical Needs Assessment Form
21	PCP On Call Coverage Arrangement Form
22	Practice Change Request Form
23	Waiver of Liability Statement Form
24	Refund Form
REFERENCE MATERIALS
26	Quick Reference Guide for Referrals and Authorizatons
27	NPI Billing Reference Guide
28	Gateway Health Plan^® Tips
29	Patient Question List

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Last Updated: 6/19/2009