Forms and Materials for Our Providers

Click on a specific form below to download and print a current version.

Administrative Forms

Accident Report
Behavioral Health Treatment Plan Preauthorization Request
Chemical Dependancy Treatment Plan Review Request
Claim Form - CMS 1500
Claim Form - UB04
Code Book Order Form 2010
Community Health Excellence Guidelines & Application 2010
Contested Refund Form
Corrected Claim Form
CPAP/BiPap Rent to Purchase Request
Disabled Dependent Certification
Preauthorization Request (Dental)
Preauthorization Request-Idaho (Medical)
Preauthorization Request-Oregon (Medical)	en Español
Prescription Drug Preauthorization Request
Referral Authorization Request
W-9

Credentialing Forms

Idaho

Attestation and Acknowledgement
Credentialing Application
Credentialing Instructions
Locum Tenens Application
Organizational Credentialing Application
Recredentialing Application

Oregon

Credentialing Application
Locum Tenens Application
Organizational Credentialing Application
Recredentialing Application

Washington

Attestation and Acknowledgement
Credentialing Application
Credentialing Instructions
Locum Tenens Application
Organizational Credentialing Application
Recredentialing Application

HIPAA Forms

834 Benefit Enrollment & Maintenance Transaction Companion Guide
835 Electronic Remittance Advice and EFT Enrollment Form
835 Healthcare Claim Payment/Advice Transaction Companion Guide
837 Dental Transaction Companion Guide
837 Institutional Transaction Companion Guide
837 Professional Transaction Companion Guide
Secure FTP Access Request
Trading Partner Enrollment Form

Informational Fliers

Electronic Claims Transmission
Expectations: A Prenatal Risk Management Program
Free and Clear
Mental Health and Chemical Dependency Parity FAQ
Mental Health and Chemical Dependency Parity Table
National Provider Identifier FAQ
New and Emerging Technologies: Coverage Status
PacificSource.com and InTouch for Providers
Specialty Pharmacy Services
Weight Management
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Last updated 3/31/2009