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Providers Review Forms

Forms

Download commonly used provider forms.

Employee Assistance Program Forms

Employee Assistance Program (EAP) Provider Experience Summary
(96 KB) Download PDF
English

Provider Address Change Requests

Please note that all billing address changes need to be submitted with a current W9

Address Change Form for All Providers (Except CA)
(66 KB) Download PDF
English
Address Change Form for California Providers
(66 KB) Download PDF
English

Utilization Management

Discharge Summary Form for All Providers (Except CA)
(52.7 KB) Download PDF
English
Discharge Summary Form for California Providers
(52.7 KB) Download PDF
English

Coordination of Care

Coordination of Care Form

Coordination of Care Form for All Providers (Except CA)
(77 KB) Download PDF
English
Coordination of Care Form for California Providers
(103 KB) Download PDF
English

Coordination of Care Instructions

Click here to listen to a short presentation about coordination of care and exchange of information
Coordination of Care Instructions for All Providers (Except CA)
(156 KB) Download PDF
English
Coordination of Care Instructions for California Providers
(165 KB) Download PDF
English

Outpatient Therapy

Outpatient Extended Care Form

Outpatient Extended Care Form for All Providers (Except CA)
(40 KB) Download PDF
English
Outpatient Extended Care Form for California Providers
(40 KB) Download PDF
English
(This form is to be used in conjunction with the Concurrent Clinical Review form in lieu of conducting a phone review with a clinical adviser.)

Neuro/Psych Testing

Neuro Psychological Testing Form

Neuro Psychological Testing Form for All Providers (Except CA)
(49 KB) Download PDF
English
Neuro Psychological Testing Form for California Providers
(49 KB) Download PDF
English

Request for Psychology Testing Form

Request for Psychology Testing Form for All Providers (Except CA)
(49 KB) Download PDF
English
Request for Psychology Testing Form for California Providers
(49 KB) Download PDF
English

Practitioner Satisfaction Survey Tool

2014 Practitioner Satisfaction Survey
(49 KB) Download PDF
English
2014 Practitioner Satisfaction Survey (CA only)
(49 KB) Download PDF
English
Printable Health Insurance Page From Humana