Institutional Provider Forms

• Refund/Deduct Authorization (offsite link)
• Room Rate Registration Form (offsite link)
• Claim/Enrollment Inquiry
• Electronic Fund Transfer (EFT) Form (offsite link)
• Other Party Liability
• Claim Appeal Representative Authorization Form * (Form 29-58)
• Limited Patient Waiver* (Form 15-169)
• OPL Deduct Authorization Form* (Form 29-203)
• Other Party Liability Questionnaire (Form 34-704)
• Predetermination Request Form * (Form 15-17)
• Prime Coverage Exception (offsite link)
• Refund/Deduct Authorization* (Form 29-202)

Click here to access professional provider forms.