SIB | Provider Forms

Certification Request Form
Electronic Funds Transfer Form

HealthChoice Provider Update Forms

Provider Change Form
Facility Change Form

Certification Forms

Use these forms to request certification of the specified medical care for your patients who have HealthChoice. Penalties are applicable for services that are not certified.

Air Ambulance
Chiropractic Treatment
Durable Medical Equipment (DME)
Home Health Care
Hospice
Infusion Therapy
Medication/Treatment Request
Mental Health
Occupational Therapy
Osteopathic Physical Medicine Treatment
Outpatient Chemical Dependency
Physical Therapy
Proton Beam Radiation Request
Speech Therapy
Synagis Request
TMD/TMJ Authorization Form
Xolair

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