Forms

Johns Hopkins HealthCare provides immediate access to required forms and documents to assist our providers in expediting claims processing for all 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)
• Model of Care Provider Training Attestation Form (D-SNP)
• 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
• 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

• Authorization for Release of Health Information - Specific Request
• Hepatitis C Therapy Prior Authorization Request
• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• Medical Injectable Prior Authorization Forms
• Member Referral
• Newborn Enrollment Notification
• Newborn Notification and Authorization Request
• Newborn Notification and Authorization Request Instructions
• Personalized Treatment Plan
• Pharmacy Compound Drug Prior Authorization Form
• Pharmacy Drug Specific Forms
• Pharmacy Non-Drug Specific Form
• Pharmacy Non-Formulary Exception Prior Authorization Form
• Pharmacy Quantity Limit Exception Prior Authorization Form
• Pharmacy Step Therapy Exception Prior Authorization Form
• Primary Care Provider Change
• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form

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)
• 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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