• 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)
• Acknowledgement of Hysterectomy Form (PDF)*
• Acknowledgement of Hysterectomy Form rev 04/2011 (PDF)*
• ODJFS Consent to Sterilization Form (PDF)**
• Federal HHS687 Consent to Sterilization Form (PDF)***
• Federal HHS687.1 Consent to Sterilization Form SPANISH (PDF)***
• Medicare Appeal Waiver of Liability Form (PDF)
• Medicare IV Home Request Process Form (PDF)
• Inpatient Prior Authorization Fax****
• Outpatient Prior Authorization Fax
• OAHP PA Home Health Form (PDF)
• OAHP PA Nursing Facility Form (PDF)
• OAHP PA Standardized Form–Medicaid (PDF)
• OB Ultrasound Prior Authorization Guide (PDF)
• OB Ultrasound Prior Authorization Form (PDF)
• Pain Management Referral Form (PDF)
• Pregnancy Event Form (PDF)
• Pregnancy Notification Form (PDF)
• Prenatal Vitamin Form (PDF)
• Provider Adjustment Request Form (PDF)
• Request to Change PCP Form (PDF)
• Vaccine Reimbursement Information and Codes (PDF)

• Member Rights & Responsibilities (PDF)
• Quick Reference Guide – Medicare (PDF)
• Quick Reference Guide – Medicaid (PDF)

*JFS 03199 rev 04/2011 Must be used as of July 1, 2012

**Not to be used as of July 1, 2012

***This form to be used exclusively as of July 1, 2012 per OAC 5101:3-21-02.2

****The procedure code is no longer required to be submitted on this form