FORMS RESOURCE

On the following pages you will find a number of forms that are provided for your convenience.

This section includes:

• Adjustments/Corrected Claims Request Form
• Claim Status Request Form
• Continuation of Authorization for IV Therapy Request Form
• Continuation of Home Health Care Authorization Request Form
• Eastern Rehabilitation Fax Cover Sheet
• Electronic Funds Transfer Authorization Form
• Obstetrical Notification/Risk Assessment Form
• Pharmacy Pre-authorization Form: General Requests
• Pharmacy Pre-authorization Form: Antidepressants
• Pharmacy Pre-authorization Form: Celebrex
• Pharmacy Pre-authorization Form: Non-sedating Antihistamines
• Pharmacy Pre-authorization Form: Physician Administered Drugs
• Pharmacy Pre-authorization Form: Proton Pump Inhibitors
• Pharmacy Pre-authorization Form: Statin Medications
• Pre-authorization Form: Infertility Therapy
• Preventive Health Checklist, Adult Patient Summary, Problem List, & Medication List
• Provider Appeal Request Form
• Standard Provider Refund Form