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US Family Health Plan Forms
US Family Health Plan provides immediate access to required forms and documents to assist our providers in expediting claims processing.
- ABA Prior Authorization Request
- Acknowledgement and Financial Responsibility Statement
- Care Management Services Request
- Medical Admission or Procedure Authorization Request (not for medical injectable requests)
- Medical Injectable Prior Authorization Request
- Newborn Notification and Authorization Request
- Newborn Notification and Authorization Request Instructions
- Non-Formulary Copay Reduction Request
- Pharmacy Brand Name Prior Authorization Request
- Pharmacy Compound Prior Authorization Request
- Pharmacy Drug Specific Prior Authorization Request
- Pharmacy Non-Drug Specific Prior Authorization Request
- Provider Appeal Submission Form
- Provider Claims/Payment Dispute and Correspondence Submission Form
- Request for Medical Appropriateness Determination for Psychological Testing
If you have any trouble downloading the above files, View Download Instructions.