Forms

We’ve simplified our prior authorization forms and fax lines to make submissions easier. Two new forms--one for inpatient and one for outpatient requests—have replaced all authorization forms previously available here.

Administrative

BlueCard Claim Appeal Form.
Change in Provider Information - Institutional/Ancillary
Please submit letterhead with this form.
Change in Provider Information – Professional
Please submit letterhead with this form.
D.C. Minor Vaccination Consent Notification Form.
Hospital Attestation for Patient Safety Initiatives
Institutional Provider Claims
Important information on the CMS Website.
Professional Provider Claims
Provider Inquiry Resolution Form
Do not use this form for Appeals or Corrected Claims. This form is to be used for Inquiries only.
Provider Refund Submission Form
Uniform Consultation Referral Form
The editable version of this form is available by logging into the Provider Portal.

Authorization/Extension Requests

NEW: Inpatient Authorization Request
NEW: Outpatient Authorization Request
Continuity of Care - Members in a Maryland Based Plan (PDF)
Continuity of Care - Provider Not in Network (PDF)
Maryland Uniform Treatment Plan Form

Behavioral Health

District of Columbia Treatment Plan Form
Maryland Uniform Treatment Plan Form

Dental Credentialing

Dental Billing Authorization Form
Dental Practice Questionnaire
Dental Provider Application
Dental Provider Application Instructions
Required Documents for Dental Credentialing
CAQH ProView Data Sheet

Institutional/Ancillary Credentialing

Facility Data Sheet
Request for Information (RFI) Application
List of Required Credentialing Documents

PCMH Member

Enhanced Monitoring Member Service Request Form - No Care Plan Required
Enhanced Monitoring Member Consent Form - No Care Plan Required
Election to Participate Form
Election to Participate Form - Large Print
Election to Participate Form
- Spanish version
Election to Participate Form
- Korean version
Revocation of Election to Participate
Revocation of Election to Participate
- Spanish version
Revocation of Election to Participate
- Korean version

PCMH Enrollment

Attachment A
Attachment B
Program Checklist
PCMH Change in Provider Information
Medical Panel Transfer Form

Pharmacy Prior Authorization

Prior authorization requests for drugs should be requested electronically through the CareFirst Provider Portal.

Drug Policies and additional information is available on the Pharmacy Prior Authorization page.

Pharmacy Forms

Brand Exception Request Form
Rx Mail Order Form

Independent Review Entity Forms

Medicare Managed Care Dismissal Case File Data Form
New Reconsideration Case File Transmittal Cover Sheet
Reconsideration Background Data Form
Reopening Request Form
New Reconsideration Case File Transmittal Cover Sheet
Statement of Compliance Form
Statement of Compliance ALJ Form