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Provider Forms 

You'll find all forms we currently use in the following list.

We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.

Botulinum Toxins Prior Authorization Form (PDF 508.59 KB) 

Change PCP Request Form (PDF 157 KB)

Coordination of Care Checklist (PDF 429.74 KB)

Critical Incident Reporting Form (PDF 177.84 KB)

Coverage Form (PDF 10.75 KB)

East and Middle Region Medical Necessity Form (PDF 10.83 KB)

Electronic Visit Verification (EVV) Data Collection Form (PDF 105.47 KB)

Episodes of Care Payment Appeals and Instructions (PDF 121.84 KB)

Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 231.68 KB) 

Group Disclosure of Ownership and Control of Interest Form | View PDF version of form (PDF 218.84 KB) 

HP Acthar Gel Prior Authorization Form (PDF 225.99 KB)

Individual Disclosure of Ownership and Control of Interest Form | View PDF version of form (PDF 267.31 KB)

Immune Globulin Prior Authorization Form (PDF 233.05 KB)

Makena Prior Authorization (PDF 229.09 KB)

Maternity Care Management Notification Form (PDF 103.79 KB)

Medicaid Identification Numbers

Panel Status Change Request Form (PDF 82.46 KB) 

Prior Authorization Fax Request Form (PDF 183.29 KB) 

Provider Dispute Form (PDF 73.16 KB)

Provider Requirements Standards Assessment and Documentation Review Form

Provider Compliance Checklist (PDF 80.53 KB)

Radiology Prior Authorization CPT Code List

Recoup Request Form 2011 (PDF 41.21 KB)

Sleep Study Worksheet (PDF 192.95 KB)

TennCare Disclosures and Medicaid ID Requirements

Title VI Article (PDF 41.06 KB)

TN Health Link Provider Attestation Form (PDF 133.1 KB) 

Universal PIN Form (PDF 37.29 KB)

Universal PIN Electronic Form (PDF 35.06 KB)

West Region Medical Necessity Form (PDF 10.52 KB)

Xolair Prior Authorization Form (PDF 508.96 KB)

Bus Pass Exemption Forms

Bus Exemption Form - Brentwood  (PDF 37.89 KB)
Bus Exemption Form - Chattanooga  (PDF 36.77 KB)
Bus Exemption Form - Kingsport  (PDF 36.77 KB)
Bus Exemption Form - Knoxville  (PDF 36.75 KB)
Bus Exemption Form - Memphis (PDF 36.74 KB)


CHOICES (Long Term Care)

Prior Authorization Fax Form
Provider Application  (PDF 93.23 KB)
Provider Change Form (PDF 112.29 KB)
UnitedHealthcare Community Plan (TennCare) Prior Authorization Fax Form


UnitedHealthcare Dual Complete (Special Needs Product (SNP)

DSNP Outpatient Observation Notification Form (PDF 35.73 KB)