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Forms

Access key forms for authorizations, claims, pharmacy and more.


Appeals & Grievances

Use this form to appoint an individual to act as a representative.

Use this form to dispute a provider payment.

Use this form to file an appeal or dispute based on a claim outcome.

Authorizations

DME Authorization Request Form

Drug Prior Authorization Requests Supplied by the Physician/Facility

Requests for prior authorization (with supporting clinical information and documentation) should be sent to ʻOhana 14 days prior to the date the requested services will be performed.

Telemedicine Authorization Request Form

Sức Khoẻ Hành Vi

Behavioral Health Service Request Form

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Nhà Thuốc

Drug Prior Authorization Requests Supplied by the Physician/Facility

Other Provider Forms


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Last Updated On: 11/25/2019
Medicare Members: Your materials are on the way! We realize you may be waiting to receive some plan materials and we apologize for any delays. Did you know you can go online to our member portal to view Member materials, review your benefits, request or download an ID card, or choose a physician (when applicable)? Log in or register today!
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