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Provider Forms & Reference Materials

PHARMACY FORMS
1

Nonformulary Drug Exception Form
2

Smoking Cessation Form
3

Synagis Prescription and Prior Authorization Request Form
GENEREAL PROVIDER FORMS & REFERENCES
1 MA30 - Hysterectomy English
2

MA30 - Hysterectomy Spanish
3

MA31 - Sterilization Form - English
4

MA300X - Medical Assistance Provider Order Forms for Providers
5

Member Outreach Form
6

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

Gateway - Asthma Action Plan
9

Gateway - Living Will Declaration
10

Gateway - Maternity Outcome Authorization Form
11

Gateway - On Call PCP Care Coverage Agreement 
12

Gateway - On Call Specialty Care Coverage Agreement 
13

Gateway - Obstetrical Needs Assessment 
14

Gateway - OB/GYN Referral Form - Sample
15

Gateway - Practice/Provider Change Request Form 
16

Gateway - Referral Form - Sample
17

CMS1450 - Uniform Billing Form & Instructions

18 W9 - Form W-9 Request for Taxpayer ID Number and Certification
19 Chlamydia Testing Consent
20 Certification for Expedited Review Form
21 Lead Screening Analysis Form
22 Member Benefit Packages / Co-Pay Matrix
23 Refund Form
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
12 Family Planning and Obstetrical Needs Quick Reference Guide
13 Neonatal Abstinence Syndrome
14 Patient Question List

Forms require the Adobe Acrobat Reader installed on your system. Most computers have this program installed. If it is not installed on your computer, you can download it for free from Adobe.

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