Provider Manual and Forms
Providers, use the forms below to work with AmeriHealth Caritas Pennsylvania Community HealthChoices.
Provider manual
Provider forms
- Claims project submission form (PDF)
- Claim refund form (PDF)
- Enrollee consent form (PDF)
- Hospital acquired conditions (PDF)
- J&B Medical Incontinence Supply (PDF)
- Long-Term Services and Supports (LTSS) Provider Change Form (PDF)
- Medical Provider Change Form (PDF)
- Obstetrical Needs Assessment Form (PDF)
- Participant eligibility verification form (PDF)
- Pennsylvania standard application (PDF)
- Pharmacy HCPCS prior authorization form (PDF)
- Pharmacy formulary addition/deletion/modification request form (PDF)
- Physician certification for an abortion (PDF)
- Recipient statement form (PDF)
- Serious reportable events in health care (PDF)
- Sterilization consent form (PDF)
- Time sheet documentation for manual EVV entries (PDF)
- W-9 form (PDF)