Forms

Johns Hopkins HealthCare provides immediate access to required forms and documents to assist our providers in expediting claims processing for all three of our lines of business.

All Health Plans

Advantage MD Forms

• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• Medication Formulary Exception Request (HMO)
• Medication Formulary Exception Request (PPO)
• Medication Coverage Determination Request (HMO)
• Medication Coverage Determination Request (PPO)
• Medication Coverage Redetermination Request (HMO)
• Medication Coverage Redetermination Request (PPO)
• Medication Step Therapy Exception Request (HMO)
• Medication Step Therapy Exception Request (PPO)
• Medication Tier Exception Request (HMO)
• Medication Tier Exception Request (PPO)
• Medication Quantity Limit Exception Request (HMO)
• Medication Quantity Limit Exception Request (PPO)
• Offshoring of PHI Attestation
• Participating Provider Post-Service Payment Dispute Submission Form
• Primary Care Provider Change
• Psychological and Neuropsychological Testing Request
• Substitute Form W-9
• Waiver of Liability Notice
• Whole Health Assessment Form
• Whole Health Assessment (Online Form)

EHP Forms

• ABA Prior Authorization Request
• Care Management Services Request
• Group Disability Claim Form (Broadway Services Inc)
• Group Term Disability Claim Form (JH Bayview Medical Center, JHH/JHHSC)
• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form
• Request for Medical Appropriateness Determination for Psychological Testing
• Substitute Form W-9

Priority Partners Forms

• Hepatitis C Therapy Prior Authorization Request
• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• Medical Review Medical Injectable Prior Authorization Request
• Member Referral
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• Personalized Treatment Plan
• Pharmacy Prior Authorization Request (non-opioid medications only)
• Pharmacy Opioid Prior Authorization Request
• Pharmacy Compound Drug Prior Authorization Form
• Primary Care Provider Change
• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form
• Synagis Prior Authorization Request

USFHP Forms

• ABA Prior Authorization Request
• Acknowledgement and Financial Responsibility Statement
• Care Management Services Request
• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• 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 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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