US Family Health Plan provides immediate access to required forms and documents to assist our providers in expediting claims processing.

• ABA Prior Authorization Request
• Acknowledgement and Financial Responsibility Statement
• Care Management Services Request
• Medical Admission or Procedure Authorization Request (not for medical injectable requests)
• Medical Review Medical Injectable Prior Authorization Request
• Newborn Notification and Authorization Request and Instructions
• Non-Formulary Copay Reduction Request
• Pharmacy Brand Name Prior Authorization Request
• Pharmacy Compound Prior Authorization Request
• Pharmacy Drug Specific Prior Authorization Forms
• Pharmacy Non-Drug Specific Prior Authorization Request
• Primary Care Provider Change Form
• Provider Appeal Submission Form
• Provider Claims/Payment Dispute and Correspondence Submission Form
• Request for Medical Appropriateness Determination for Psychological Testing

PLEASE NOTE: All forms will need to be faxed to US Family Health Plan in order to be processed. See the appropriate fax number on the top of the form for submission. If you have any questions, please contact Customer Service at 800-808-7347.