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 Review Request
Chemical Dependancy Treatment Plan Review Request
Claim Form - CMS 1500
Claim Form - UB04
Code Book Order Form 2011
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 (Fax)
Referral Authorization Request
W-9

Credentialing Application
Locum Tenens Application
Organizational Credentialing Application
Recredentialing Application

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

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

Diagnostic Imaging Management FAQ
Diagnostic Imaging Preauthorization List
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
Who To Contact
Who To Contact-Idaho

Access your PacificSource account information 24/7.

Please contact Idaho Physicians Network (IPN) or the BrightPath Network for credentialing information.

Phone: 208.333.1513 or 866.476-1076
E-mail: ipn@ipnmd.com

Complete the online BrightPath Provider Nomination form, or call 208.381.1564

Last updated 3/25/2010