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Provider Forms & Reference Materials

PHARMACY FORMS
1

Nonformulary Drug Exception Form
2

Smoking Cessation Form
GENEREAL PROVIDER FORMS & REFERENCES
1 MA30 - Hysterectomy English
2

MA30 - Hysterectomy Spanish
3

MA31 - Sterilization Form - English
4
5

MA300X - Medical Assistance Provider Order Forms for Providers
6

Member Outreach Form
7

CMS-1500 - Health Insurance Claim Form
8 Gateway - Asthma and Cardiac Referral Fax Form
9

Gateway - Asthma Action Plan
10

Gateway - Living Will Declaration
11

Gateway - Maternity Outcome Authorization Form
13

Gateway - On Call PCP Care Coverage Agreement 
14

Gateway - On Call Specialty Care Coverage Agreement 
15

Gateway - Obstetrical Needs Assessment 
16

Gateway - OB/GYN Referral Form - Sample
17

Gateway - Practice/Provider Change Request Form 
18

Gateway - Referral Form - Sample
19

CMS1450 - Uniform Billing Form & Instructions

20 W9 - Form W-9 Request for Taxpayer ID Number and Certification
21   Chlamydia Testing Consent
22 Certification for Expedited Review Form
23   Lead Screening Analysis Form
24 Member Benefit Packages / Co-Pay Matrix
REFERENCE MATERIALS
1 DIVA Instructions on Reviewing Referral
2 DIVA Instructions on Entering Referral
3 Environmental Assessment Standards
4 Obstetrical Needs Assessment Form Review
5 Obstetrical Needs Assessment Form FAQ's
6 Private Duty Nursing Billing Guidelines
7 Referral and Authorization Cheat Sheet
8 Gateway Health Plan® Tips
9 Sample Capitation Reports
10 Electronic Billing Companion Document
11 Adjustment Code Crosswalk

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