Provider Forms

Provider Contact and Location Information Updates

Please complete the appropriate form below to let us know of changes in contact information for staff or locations:

Required Notification Forms

  • Nursing Home Notification Form
    Submit this form to report member absences, RUGS score updates, and Hospice enrollment. This form is required as of 01/01/2017 to ensure that nursing home claims are authorized and paid at the accurate RUGS level.
  • Member Absence Notification Form 
    Submit this form when a member is temporarily out of an AFH, CBRF, or RCAC facility. This form is required as of 01/01/2017.
Other Forms

W-9 Form (Request for Taxpayer Identification Number)
Click the link above to go to the IRS site for the W-9 form. You can fill this form out on your computer, and then print and mail or fax it to us. Adult Family Home and CBRF providers must also complete the Adult Family Home/CBRF Additional Tax Information Form.
 

Also see these pages for relevant forms:

Provider Portal

Claims and Billing Information

Provider Application and Contracting