Provider Downloadable Forms

The following forms are available for providers (in PDF Adobe Acrobat format) and are online-fillable.  Please download and use the forms as needed and please follow the directions on the form.

This form must be completed by the provider prior to admitting a patient to an Out-of-Network or Non-Beat It! Provider. This form must also accompany the UNDERSTANDING MY FINANCIAL RESPONSIBILITY to be completed by the patient or subscriber. Both forms must be submitted in order to receive an authorization code.

The purpose of this form is to ensure that our participants understand the difference between an In-Network Provider vs. Out-of-Network Provider and their potential financial responsibility.  In order to receive an Out-of-Network Treatment Authorization this form must be completed by the participant/subscriber and be submitted along with the Out-of-Network Pre-Authorization Form, which is to be completed by the provider.

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