Health Care Forms

Download and print a health care form:

• Allowables Request (PDF)
• APRN/PA Competency Form (PDF)
• Authorization for the Release of Protected Health Information (PDF)
• AZ Prior Authorization Request Form (PDF)
• Behavioral Health Injectable Antipsychotic Prior Authorization Form (Genoa Pharmacy) (DOC)
• Claims Reconsideration Form (PDF)
• Hospital Based Provider Enrollment Form (PDF)
• HPN and SHL Provider Demographic Update Form (PDF)
• HPN BH Initial Review Form for Inpatient, RTC, Inpatient SUD Residential, PHP and IOP
• Initial Credentialing Form (PDF)
• Medical Necessity Request Form (PDF)
• New Prescription Fax Order Form (PDF)
• New Prescription Mail-in Order Form (PDF)
• Nevada Claim Form (PDF)
• Oncology Step Therapy Exception Prior Authorization Form (DOC)
• Behavioral Health Outpatient Treatment Request Form (DOC)
• Pharmacy Reimbursement Claim Form (PDF)
• Primary Care Physician Change Form (PDF)
• Prior Authorization Form (PDF)
• Recredentialing Form (PDF)
• QOC Internal Referral Form (PDF)
• Substance Abuse Records Release Form
• Transition of Care and Continuity of Care Form (PDF)
• Transplant Referral Fillable Form (PDF)

If you don't find the form you’re looking for, contact Provider Services.