Provider Supply Line Order Form

Most of the information available through this form can also be found on our website at www.amerihealth.com or on the NaviNet^® web portal. If you cannot find what you’re looking on our website or do not have access to NaviNet, please continue completing the form below.

Your request will be processed and delivered within five to seven business days.

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Your Information

*First Name: « Required

*Last Name: « Required

*Title: « Required

*Email: « Required

Provider/Office Information

*Provider/Office Name: « Required

*Street Address 1: « Required

Street Address 2:

*City: « Required

*State: « Required

*ZIP: « Required

*County: « Required

*NPI or 10-digit ID: « Required

*Phone Number: « Required

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Please select the items you wish to request.

Behavioral Health Overview Guides

Depression Treatment Overview:

Substance-Use Disorders Identification Overview:

Attention Deficit/Hyperactivity Tip Sheet:

Adult Bipolar Disorder Tip Sheet:

Health Care Reform

Health Care Law & You guide — 10/pack:

Health and Wellness Material

Alcohol Screening in Primary Care (PA) — 25/pack:

Baby FootSteps^® Program enrollment flyer (PA) — 25/pack:

Help Patients Quit Tobacco (PA) — 25/pack:

Perinatal Care Guidelines (PA):

Clinical Practice Guidelines Summary (PA):

Member Wellness Guidelines (PA):

Children (birth to 17):

Adults (18 to 64):

Adults (65 and older):

Manuals

Provider Manual for Participating Professional Providers (PA):

Newsletters

Partners in Health Update^SM — issued monthly:
Request #1:

Request #2:

Request #3:

Provider Publication Cumulative Index — issued annually since 2002:

Stickers

Allergy stickers — 10 sheets (210 stickers)/pack:

Missed appointment stickers — 10 sheets (210 stickers)/pack:

Other materials, including forms and patient resources, are available at:

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.

If you still don’t see what you are looking for, or if you need to order larger quantities, please contact the Provider Supply Line at 1-800-858-4728.