• Abortion Certification Form (PDF)
• Advance Directives Form (PDF)
• Care Management Referral Form EC (PDF)
• Care Management Referral Form NE (PDF)
• Care Management Referral Form NW (PDF)
• Care Management Referral Form SW (PDF)
• COB Dispute & Adjustment Request Form (PDF)
• CONNECTIONS Referral Form (PDF)
• Consent to Hysterectomy Form (PDF)*
• ODJFS Consent to Sterilization Form (PDF)**
• Federal (HHS-687) Consent to Sterilization Form (PDF)**
• Imaging Prior Authorization Request Form (PDF)
• Medicare Appeal Waiver of Liability Form (PDF)
• Medicare IV Home Request Process Form (PDF)
• OAHP PA Forms Instructions (PDF)
• OAHP PA Home Health Form (PDF)
• OAHP PA Nursing Facility Form (PDF)
• OAHP PA Standardized Form–Medicaid (PDF)
• OB Ultrasound Prior Authorization Guide & FAQ (PDF)
• OB Ultrasound Prior Authorization Form (PDF)
• Pain Management Referral Form (PDF)
• Pre-Service Fax Request Form (PDF)
• Pregnancy Event Form (PDF)
• Pregnancy Notification Form (PDF)
• Provider Adjustment Request Form (PDF)
• Request to Change PCP Form (PDF)
• Vaccine Reimbursement Information and Codes (PDF)

• Member Rights & Responsibilities (PDF)
• Quick ReferenceGuide – Medicaid (PDF)
• Quick Reference Guide – Medicare (PDF)
• Web Authorization Process Information (PDF)

*The 2009 ODJFS form may be used at any time.The 2003 version will be acceptable as long as the date the member signed it occurs on or before June 30, 2010.**The 2009 ODJFS form or the 2006 federal form (HHS 687) may be used at any time. The 2003 version may still be accepted as long as it is dated (item 8, member’s signature and date) on or before June 30. Theoretically, a 2003 form could be accepted up until December 27, 2010 if it was signed on June 30, 2010. After this there will be no circumstances in which the 2003 form will be acceptable.