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Home > Providers > Provider Manual and Forms

Provider Manual and Forms

Providers, use the forms below to work with AmeriHealth Caritas Pennsylvania Community HealthChoices.

Provider manual

  • Download the provider manual (PDF)
  • 2022 provider manual updates (PDF)

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)
  • W-9 form (PDF)

Prior authorization forms

  • Chiropractic Request (PDF)
  • Genetic Testing (PDF)
  • Hospital Notification of Emergent Admissions (PDF)
  • Outpatient Therapy/Cardiac or Pulmonary Rehab Request (PDF)
  • Pain Management Injection Request (PDF)
  • Prior Authorization Form (PDF)
Providers
  • Join our network
  • Prior authorization lookup tool
  • Find a doctor, drug, or pharmacy
  • Provider manual and forms
  • Pharmacy services
  • Claims and billing
  • Training
  • Resources
  • Sign up for email alerts
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