Forms

The following forms are available for providers:

AIM Preauthorization/RQI Request Fax Form
Case Management Referral Form
Connections Physician’s Referral Form — for eligible members
Continuation of Care Form
Emergency Room Review Form
FutureScripts^® Direct Ship Specialty Pharmacy Program
FutureScripts^® Direct Ship Specialty Pharmacy Vaccine Program
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
Non-Formulary Exception Request
Overpayment Refund Form
PCP to Behavioral Health Provider Communication Form
Physician Certificate of Attestation Form
Provider Claim Inquiry Form
Provider Change Form
Surgical Team (Modifier -66) Documentation Form

A request form must be completed for all medications requiring prior authorization. Please click on the link below for the applicable Prior Authorization form.

Prior Authorization Forms for prescription drugs

For copies of the Baby FootSteps^® Initial Maternity Patient Questionnaire, call the Provider Supply Line at 1-800-858-4728.

Please note that claim forms, such as the CMS-1500, are not available through the Provider Supply Line; they are available for purchase at many local office supply stores.

To verify member eligibility or check the status of a claim, please use the NaviNet^® web portal or call 1-800-275-2583 to access the Provider Automated System.

For all other questions and inquiries, call Customer Service at 1-800-275-2583.