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Provider Login

Provider Forms

Use the links below to download these popular forms.

  • CareWeb Provider Connection Security Request Form
  • Referral Form for Authorization
  • Referral Form for Case Management
  • Referral Form for Clinical Trials
  • Referral Form for Medical Drug Authorization

 

  • Referral Form - Behavioral Health
  • Referral Form - Psychological Neuropsychological Testing
  • Medicare Reopen Form

 

  • Request for Claim Inquiry
  • Provider Connection Claim Status Request Form
  • Provider Negotiation Request Form
  • Provider Dispute Resolution Form (Not for claim issues. Please use the Claim Inquiry form.)

 

  • Oklahoma Advance Directive for Health Care
  • Waiver of Liability Form
  • Appointment of Representative Form
  • Physician Complaint Form
  • Commercial Prescription Coverage Determination Form (Large Group, Grandfathered and Traditional Plans)
  • QHP Coverage Determination Form (Small Group and Individual ACA Plans)

 

  • Walgreens Commercial Physician Fax Form
  • Walgreens Mail Service Physician Fax Form
  • Walgreens Specialty Physician Referral Forms
  • CVS Specialty Physician Referral Forms

Use the links below to download the EFT / ERA Enrollment Forms and Instructions.

  • Echo Health Payment Solutions EFT_ERA
 
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