Forms
- Appointment of Representative & Authorization to Release (PDF)
- Appointment of Representative for Medicare Members (PDF)
- Member Appeal Request (PDF)
- Accident and Injury Incident Questionnaire/Other Party Liability (PDF)
- Claims Support Documentation (PDF)
- CMS-1450 (UB-04) Claim (PDF)
- CMS-1500 Health Insurance Claim (PDF)
- EDI Trading Partner Setup Request
- Provider Update Forms
- EFT Enrollment
- Healthcare Delivery Organization Application
- Lab Requisition (PDF)
- Network Funding Agreement (PDF)
- NPI Update/Application (PDF)
- Physician Selection/Change (PDF)
- W-9: Request for Taxpayer ID Number and Certification (PDF)
- KP Washington Specialty Home Infusion Formulary (PDF)
- Agalsidase (Fabrazyme) prescription referral (PDF)
- Aglucosidase (Lumizyme) prescription referral (PDF)
- Alpha-1 proteinase inhibitor prescription referral (PDF)
- Eculizumab (Soliris) prescription referral (PDF)
- Eteplirsen (Exondys 51) prescription referral (PDF)
- Galsulfase (Naglazyme) prescription referral (PDF)
- Golimumab (Simponi Aria) prescription referral (PDF)
- Imiglucerase alfa (Cerezyme) prescription referral (PDF)
- Idursulfase (Elaprase) prescription referral (PDF)
- Infliximab prescription referral (PDF)
- IVIG prescription referral (PDF)
- Ocrelizumab (Ocrevus) prescription referral (PDF)
- Rituximab (Rituxan & Truxima) prescription referral (PDF)
- Taliglucerase alfa (Elelyso) prescription referral (PDF)
- Trastuzumab prescription referral (PDF)
- Vedolizumab (Entyvio) prescription referral (PDF)
- Velaglucerase alfa (Vpriv) prescription referral (PDF)
- Addiction and Recovery Reauthorization Request (Word)
- AUDIT alcohol questionnaire (PDF)
- Clinical Information Request Form (PDF)
- Eating Disorder Reauthorization Request (Word)
- Mental Health and Wellness Patient Experience Survey (PDF)
- Mental health intensive outpatient services (PDF)
- Mental Health Provider Treatment Record Review
- Mental Health Therapy Authorization/Reauthorization Request (PDF)
- Methadone Reauthorization Request (Word)
- Psychiatric Medication Management Reauthorization Request (PDF)
- Psychological Testing Authorization Request (Word)
- Suboxone Reauthorization Request (Word)
- Sample: Eating Disorder Reauthorization Request (PDF)
- Sample: Psychiatric Medication Management (Without Therapy) Reauthorization Request (Word)
- Well-Being Mental Health Therapy Reauthorization Request (PDF)
- Abecma Prior Authorization Form (PDF)
- Breyanzi Prior Authorization Form (PDF)
- Chronic High-Dose Opioid Therapy Prior Authorization Form (PDF)
- Kymriah Prior Authorization Form (PDF)
- Tecartus Prior Authorization Form (PDF)
- Yescarta Prior Authorization Form (PDF)
- Claims Second-Level Reconsideration
- Provider Reconsideration Request - Referrals and Medical Necessity