We provide you with forms and tools to save you time.
If you have questions about filling out and submitting online or paper forms, please contact customer service.
Appeals
- Appeal Request Form (Medicaid and Cascade Select only. Click here for the Medicare Advantage form)
- Consent for Appeal Form (English)
- Consent for Appeal Form (Spanish)
Applied Behavior Analysis (ABA): Autism Spectrum Disorder
Behavioral Health Resources
- Behavioral Health and Substance Use Disorder
- Mental Health Technology Transfer Center Network (MHTTC) – Training and technical assistance (TA) in evidence-based practices (EBP)
- Evidence-Based and Research-Based Best Practices – Reporting Guidelines (HCA)
- IMC Evidence-Based Practices Reporting Guidelines
- Clinical Practice Trainings and Resources for Integrated Managed Care
- Depression Screening for Caregivers (Children & Youth)
- Seattle Children’s Partnership Access Line (PAL)
- Partnership Access Line (PAL) for Moms
- Patient Health Questionnaire (PHQ) Screeners
- CALOCUS
- CALOCUS Score Sheet
- LOCUS
- LOCUS Score Sheet
Care Management/Quality
- Dialysis Notification Form
- Care Management Referral Form
- Care Management Referral Programs
- Chemical Dependency OTR Form
- Critical Incident Form
- Mental Health OTR Form
- My Life Plan – A Person-Centered Planning Guide is funded by the Washington State Developmental Disabilities Council.
- Patient Complaint Form
- Pregnancy Notification Form
- Psych/Neuropsych Testing Request Form
- Quality Improvement Program
Child and Adolescent Behavioral Health
Claims
- Claims Supporting Documentation Cover Sheet
- Corrected Claim – Standard Cover Sheet
- Hysterectomy Consent Form: Prior authorization and a consent form are required for hysterectomy. See our Provider Manual for more information.
- Sterilization Consent Form: A consent form is required for sterilization. See our Provider Manual for more information.
- Sterilization Consent Form – Spanish: A consent form is required for sterilization. See our Provider Manual for more information.
- 1500 Claim Form and Instructions
- UB04 Claim Form and Instructions
Compliance
- Authorization to Disclose Protected Health Information
- Authorization to Release Confidential Substance Use Disorder Treatment Information
- Fraud, Waste, and Abuse Training Attestation Form (online)
- Ownership and Control Interest Disclosure Form (online)
- Ownership and Control FAQ
- Report Potential Fraud Form
- Report Potential Privacy/Security Incident Form
EDI Support
See our Provider Manual for more information about electronic transactions.
Provider Network Enrollment
Pharmacy
Medication Assisted Treatment (MAT) Program
- Buprenorphine Monotherapy Prior Authorization Form
- Guidelines for Buprenorphine Containing Products
- Guidelines for Naltrexone Containing Products
Opioid Prescription
- Information on the HCA Opioid Policy
- Opioid Attestation Form: Fax the completed attestation form to Express Scripts at 1-877-251-5896
- Opioid Agonists Medical Policy
- Pharmacy Expedited Authorization Codes
Provider Updates
- Clinic and Group Add Change Term Form (Please open in Chrome browser)
- Clinic and Group Add Change Term Form (online)
- Clinic and Group Add Change Term Form (PDF)
- Core Provider Agreement for Medicaid Services FAQ
- Provider Add Change Term Form (Please open in Chrome browser)
- Provider Add Change Term Form (online)
- Provider Add Change Term Form (PDF)
- Provider Directory Intake Form
- Behavioral Health Provider Roster
Tools and Resources
Utilization Management
- Dialysis Notification Form
- Exception to Rule Request Form (Apple Health Only)
- Hearing Aid Prior Authorization Request Form
- Limitation Extension Form
- Inpatient Admission Form
- Prior Authorization
- Stage 2 Bariatric Surgery Request
- Standard Referral Form
- SYNAGIS – Statement of Medical Necessity
- Skilled Nursing Facility (SNF) Request Process
