Forms for Download
Prior Authorization Forms
- Envolve Pharmacy Solutions Medicaid (All plans use this form unless otherwise noted in list below)
- Envolve Pharmacy Solutions (Pennsylvania and Ohio)
- Envolve Pharmacy Solutions (California Only)
- Envolve Pharmacy Solutions Suboxone
- California (CH&W/Medi-Cal/CalViva)
- Coordinated Care Washington
- Coordinated Care Washington Buprenorphine Monotherapy
- Coordinated Care Washington Opioid Attestation
- Coordinated Care Washington Palivizumab
- Iowa Total Care
- Magnolia Health (Mississippi)
- Nebraska Total Care
- NH Healthy Families
- NH Healthy Families Behavioral Health for Community Mental Health Center Providers (PDF) (To complete this form electronically, please visit CoverMyMeds)
- Next Level Health
- State of Louisiana
- Sunflower Health Plan
- Sunshine State Florida
- Superior HealthPlan
- YouthCare HealthChoice Illinois
- Ambetter (Arizona, Florida, Georgia, Illinois, Indiana, Kansas, Michigan, Mississippi, Missouri, Nevada, New Mexico, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee)
- Ambetter Arkansas
- Ambetter Washington
Additional Forms
- Authorization to Disclose Health Information - English
- Authorization to Disclose Health Information - Spanish - or Autorizacion para Divulgar Informacion Medica
- Revocation of Authorization to Disclose Health Information - English
- Revocation of Authorization to Disclose Health Information Form - Spanish - or Revocacion de la Autorizacion para Divulgar Informacion Medica