Forms

The forms most frequently needed by Fallon providers are listed below.

Claims and appeals

• Health Insurance Claim Form (pdf)
• Request for Claim Review Form and Reference Guide (pdf)
• Third Party Liability Indicator Form (pdf)
• Waiver of Liability Statement (pdf)

Doing business with Fallon Health

• Material Request Form
• OB/GYN Provider Attestation Form - Fallon ACO plans only (pdf)
• ProAuth Enrollment Request Form (pdf)
• Register for Provider Tools and electronic data submission
• Update your practice information
• Standardized Provider Update Form (pdf) 

Forms for your patients (our members)

• PCP selection/change form (pdf)

Pharmacy

• NaviCare HMO SNP and SCO Oral Nutritional Supplements: Medical necessity review and prescription (pdf)
• Pharmacy Prior Authorization Forms
• Special Formula Medical Necessity Form (pdf)

Referrals and authorizations

• Case Management Referral Form (pdf)
• Disease Management Referral Form  (pdf)
• Infertility Services Prior Authorization Request Form (pdf)
• MCE Behavioral Health Provider/Primary Care Provider Communication Form (pdf)
• ProAuth Enrollment Request Form (pdf)
• Safe Transitions Referral Form (pdf)
• Skilled Nursing Facility Admission Review Request (pdf)
• Skilled Nursing Facility Request for Continued Stay Form (pdf)
• Standardized Prior Authorization Request Form (for non-pharmacy PAs)
• Universal Health Plan/Home Health Authorization Form (pdf) 
   

  Is there an additional form or two you would like listed here? Let us know!