UnitedHealthcare Community Plan
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Provider Forms


You'll find all forms we currently use in the following list. Check back frequently to get the most current and up-to-date forms.

Note – Indian Health Services (IHS), Tribal 638 facilities, Skilled Nursing Facilities (SNF) and Home and Community Based Service (HCBS) providers are not required to use the reconsideration form.  These facilities should continue working with their designated points of contact within UnitedHealthcare Community Plan of New Mexico.


BH ABA Level of Care Guidelines (PDF 94.36 KB)

BH ABA Stage 1: Diagnostic Risk Evaluation and ISP Form (PDF 113.14 KB)

BH ABA Stage 2: Assessment Form (PDF 113.33 KB)

BH ABA Stage 3: Planning and Treatment Initial Form (PDF 157.54 KB)

BH ABA Stage 3: Planning and Treatment Concurrent Form (PDF 220.02 KB)

BH Concurrent Clinical Review Form (DOCX 27.68 KB)

BH Discharge Clinical Notification Form (DOCX 23.27 KB)

BH Fax Prior Auth/Notification Cover Page (DOCX 323.61 KB)

BH Initial Clinical Review Form (DOCX 30 KB)

BH Retrospective Clinical Review Form (DOCX 28.33 KB)

Centennial Care FWA Allegation Form (PDF 37.76 KB)

Centennial Care Pharmacy Prior Authorization Form (PDF 78.35 KB)

Centennial Care Prior Authorization Form (PDF 100.14 KB)

Centennial Care Provider Appeal Form (PDF 40.1 KB)

Centennial Care Provider Demographic Changes Form (PDF 257.87 KB)

EVV No Tech Zone Attestation_multibranch Form (PDF 259.25 KB)

Facility Participation Agreement (PDF 169.68 KB)

Medical Group Agreement (PDF 156.8 KB)

NM 2015 State of NM  Joint MCO Centennial Medicaid Disclosure Form

Nursing Facility Auth Research Form (PDF 9.53 KB)


Health Assessment Forms

1) Health Assessment- Child (Under 21) (PDF 566.19 KB)

2) Health Assessment - Adult (21 and over) (PDF 566.05 KB)