Access Forms

Download important forms below.

Claim Forms

PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form

Appeal Forms

PDF icon Health Plans General Provider Appeal Form (non HPHC)

PDF icon Harvard Pilgrim Provider Appeal Form and Quick Reference Guide

Request for Network Exception 

PDF icon Network Exception Request Form

Prior Authorization Forms

Please note: Prior authorization requirements vary by plan. Please contact HPI Provider Services or log in to Access Patient Benefits and review your patient's plan description for a full list of services requiring prior authorization. Prior authorization forms below are only for plans using AchieveHealth™ CMS. Please verify the correct prior authorization vendor prior to submitting forms; unverified prior authorizations wil be returned.

AchieveHealth® Precertification List

PDF icon Standard Prior Authorization Request

If your patient's plan requires Prior Authorization for a service or procedure listed below, please complete the Standard Prior Authorization Request form in addition to the applicable form below.

PDF icon Bariatric Surgery Precert Questions (Mandatory)

PDF icon Chemotherapy/Cancer Treatment Medication
PDF icon Chemotherapy Support Drugs

PDF icon Pediatric/Adult Formula

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