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 Review 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

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