Certification Request Form

Electronic Funds Transfer Form

Certification Forms

Use these forms to request certification of the specified medical care for your patients who have HealthChoice. Penalties are applicable for services that are not certified.

• Air Ambulance
• Chiropractic Treatment
• Durable Medical Equipment (DME)
• Home Health Care
• Hospice
• Infusion Therapy
• Medication/Treatment Request
• Mental Health
• Occupational Therapy
• Osteopathic Physical Medicine Treatment
• Outpatient Chemical Dependency
• Physical Therapy
• Proton Beam Radiation Request
• Speech Therapy
• Synagis Request
• TMD/TMJ Authorization Form
• Xolair