Claims & Reimbursement

Prior Authorization and Referral

• Claim Adjustment Request Form
• Prior Authorization Request Form (NY/NH/VT)

• Appendix A: Rochester Region Prior Authorization List
• Appendix B: Rochester Region Notification List
• Prior Authorization Request Form for DME/O&P Items & Services

easyLink Forms

• Provider Web Site Access Form

Forms for Rochester-Based Providers

• Federal Tax W-9
• CAQH Provider Data Form
• Provider Data Change Form
• NP/PA Registration Form
• CRNA Registration Form
• Anesthesiologist Registration Form
• Emergency Physician Registration Form
• Hospitalist Registration Form
• Locum Tenens Registration Form
• Neonatologist Registration Form
• Pathologist Registration Form

Medical Forms

• Infertility History & Treatment Plan for Gonadatropins
• Supplemental Nutrition Form
• Neck & Upper Back Pain Exam
• Lower Back Pain Exam

Forms for Providers from All Other Regions

• Federal Tax W-9
• Provider Directory Listing Change Form

• Mid-Level Practitioner Registration Form

Change & Referral Forms

• Primary Care Physician (PCP) and OB/GYN Change Form / PCP Patient Re-assignment Request

• Referral Fax Form

Pharmacy

Prior Authorization Forms

• Medication (General & Formulary Exceptions)
• Antifungals
• ARBs
• Arthritis, Biologic Agents
• Blood Modifiers - Anemia
• Chronic Hepatitis C Coverage
• Cox II Inhibitors
• Growth Hormone
• Hypnotics
• Immunoglobulin Therapy
• Inflammatory Bowel Disease
• Leukotriene Modifiers
• Proton Pump Inhibitors
• Psoriasis
• Restasis
• Smoking Cessation
• Synagis
• Weight Loss
• Xolair

Pharmacy prior authorization forms are for commercial and Medicare Part B requests only.

• B vs D - Oral Chemotherapy & Immunosuppressants
• B vs D - Anti-emetics
• B vs D - Nebulizer Solutions
• Medicare Standard Form

Other Forms

• Patient Medication List Form
• Lupron Depot Order Form

Planning and Review

• Abdominal Hysterectomy with or without Bilateral Sapingo-oophrectomy (BSO) Review Tool
• Laparoscopic Supracervical Hysterectomy with or without Bilateral Sapingo-oophrectomy (BSO) Review Tool
• Laparoscopically Assisted Vaginal Hysterectomy with or without Bilateral Sapingo-oophrectomy (BSO) Review Tool

• Plantar Fascial Release Review Tool
• Prenatal Risk Form
• Radiology Review Tool
• Total Hip Replacement Review Tool
• Total Knee Joint Replacement Review Tool
• Septoplasty Review Tool
• Advanced Care Planning