Forms

Access the links below for essential forms and documents providers need to best serve our members.

Contracting and Practice Changes Forms

• New Health Partner Contract Form
  For guided assistance, refer to the Becoming a Health Partner Step-by-Step Guide.

Member-Related Forms

• Coordination of Health Care Exchange Information FAQ
  Refer to the FAQ document for additional information about coordination of care and sharing patient care information with another provider.
• Coordination of Health Care Exchange Information Form
  Use this form to exchange information between health care providers and coordinate care on behalf of members.
• Interpreter Services Request Form
• PCP Change Request Form

Pharmacy Prior Authorization Forms

Gainwell Technologies handles prior authorization requests for drugs billed through the pharmacy point of sale (POS) venue. If you are a Mississippi Medicaid prescriber, please submit your prior authorization requests through the Gainwell provider web portal (preferred route) or fax completed prior authorization forms to the number below.

• Toll-free: 1-833-660-2402
• Fax: 866-644-6147

Change in Facility Request Form

Specialty Pharmacy Prior Authorization Form

Medical Prior Authorization Forms

• Medical Prior Authorization Form
• Additional Forms Coming Soon 

Claims Forms

• How to Submit Abortion, Hysterectomy, and Sterilization (AHS) Consent Forms
• Overpayment Recovery Form

Appeals Forms

• Consent for Provider to File an Appeal on Patient/Member’s Behalf
• Expedited Appeal Form
• Standard Provider Appeal Request Form

Fraud, Waste and Abuse Forms

• Additional Forms Coming Soon