Provider Forms

Frequently Used Forms

The following are forms for providers who work with Aspirus Health Plan. Additional forms, information and instruction may be found on the individual pages related to relevant topics.

Join our Network 

Credentialing

Uniform Practitioner Credentialing Application (PDF)
Uniform Facility Credentialing Application (PDF)

Update/ Manage your Information

Uniform Practitioner Add-Change Form (PDF)
Non-credentialed Practitioner Add Form (PDF)
Non-credentialed Practitioner Change Form (PDF)
Non-credentialed Practitioner Terminate Form (PDF)
Location Add Form (PDF)
Location Demographic/Update Form (PDF)
Location Close Form (PDF)
Provider Notification Change/Update/Termination Third-Party Agreement (PDF)

Prior Authorizations, Notifications and Referrals

Medical

AIR/LTAC Admission Notification Form (PDF)
DME/Supply Prior Authorization Request Form (PDF)
General Prior Authorization Request Form (Not used for mental health services or medical drug authorization requests) (PDF)
Hospice Election Communications Form (PDF)
Medical Injectable Drug Authorization Request Form (PDF)
Nursing Home/ Swing Bed Admission Notification (PDF)
Prior Authorization Genetic Testing Form (PDF)
Pre-Determination Request Form (Not used for medical drug pre-determinations) (PDF)
Transplant Services Notification Form (PDF)

Mental Health/Substance Use Disorder 

Prior Authorization Mental Health Outpatient Services (PDF)
Substance Use Disorder (SUD) Outpatient Services (PDF)
Prior Authorization for Out-of-Network Mental Health & Substance Use Disorder Services (PDF)
Notification of Inpatient Mental Health Admission (PDF)
Notification of Inpatient Substance Use Disorder (PDF)
Release of Information Form (PDF)

Referrals

Disease Management Referral Form (PDF)
Care Management Referral Form (PDF)

Claims and Billing

Provider Claim Reconsideration Request Form (PDF)
Health Care Claim Attachment Cover Sheet (PDF)
Waiver of Liability Statement (PDF)
Provider Notification Change/ Update/ Termination Third-Party Agreement (PDF)

Pharmacy

For all provider-related pharmacy forms, including prior authorizations for medical injectable drugs, please visit the Pharmacy page.

Denials

Notice of Medicare Non-coverage (Advance Notice) (NOMC)
NOMNC Valid Delivery Documentation Form (PDF)
Detailed Explanation of Non-Coverage Form (DENC) 
NDMCP – Notice of Denial of Medical Coverage (NDMC)

For denial form instructions, please visit the Denials page.

Medical Necessity Criteria