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Forms
The following forms are available for providers:
AIM Preauthorization/RQI Request Fax Form
Connections Physician’s Referral Form
— for eligible members
Continuation of Care Form
Direct Ship Injectable Request Form
Emergency Room Review Form
HIPAA Authorization Form
— authorizes AmeriHealth to release member’s health information
HIPAA Personal Representative Form
— appoints another person as member’s personal representative
Member Consent For Financial Responsibility Form
New Jersey Provider Appeals Claim Form
Overpayment Refund Form
PCP to Behavioral Health Provider Form
Populated Sample CMS-1500 (08/05) Claim Form with Instructions
Physician Claim Inquiry Form
Prior Authorization Forms for prescription drugs
Provider Change Form
Surgical Team (Modifier -66) Documentation Form
Additional provider forms are available by calling the Provider Supply Line at 1-800-858-4728.