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
Prior authorization requests for provider administered drugs billed through the medical benefit are handled by TrueCare. Please submit your prior authorization requests through the TrueCare provider portal or fax the completed Specialty Pharmacy Prior Authorization Form (found below) to 888-399-0271.
Medical Prior Authorization Forms
Claims Forms
- How to Submit Abortion, Hysterectomy, and Sterilization (AHS) Consent Forms
- Itemized Bill Cover Sheet
- 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
- Fraud, Waste and Abuse Reporting Form: Use this form if you think that a member, provider, or pharmacy is taking part in fraud, waste, abuse or overpayment.