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

• Authorization Request Form
• 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 
• Provider Update
• 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
• Authorization Request Form
• Care Management Services Request
• Group Disability Claim
• 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
• Synagis Prior Authorization Request

Priority Partners Forms

• Authorization Request Form
• Hepatitis C Therapy Prior Authorization Request
• Medical Review Medical Injectable Prior Authorization Request
• Member Referral
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• 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
• Authorization Request Form
• Care Management Services Request 
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• 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
• Synagis Prior Authorization Request
• Uniform Treatment Plan

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