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 Review Medical Injectable Prior Authorization Request
• Medication Formulary Exception Request (HMO)
• Medication Formulary Exception Request (PPO)
• Medication Coverage Determination Request
• Medication Coverage Redetermination Request
• 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
• Prior Authorization Request
• Provider Update
• Psychological and Neuropsychological Testing Request
• Sub W-9
• Waiver of Liability Notice
• Whole Health Assessment Form

EHP Forms

• Behavioral Health Services Referral
• Care Management Services Request
• Group Disability Claim
• Medical Review Medical Injectable Prior Authorization Request
• 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
• Sub W-9
• Synagis Prior Authorization Request

Priority Partners Forms

• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form
• Hepatitis C Therapy Prior Authorization Request
• Medical Review Medical Injectable Prior Authorization Request
• Member Referral
• Member Response
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• Pharmacy Prior Authorization Request (non-opioid medications only)
• Pharmacy Opioid Prior Authorization Request
• Primary Care Provider Change
• Synagis Prior Authorization Request

USFHP Forms

• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form
• Acknowledgement and Financial Responsibility Statement
• Care Management Services Request 
• Medical Review Medical Injectable Prior Authorization Request
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• Pharmacy Compound Prior Authorization Request
• Pharmacy Prior Authorization Request
• Uniform Treatment Plan
• Synagis Prior Authorization Request
• Request for Medical Appropriateness Determination for Psychological Testing

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