Medicaid Prescription Mail-Order Form – Use this form to mail order new or refill prescription maintenance medicines. Mail the completed form to the address on the form. You must include the original prescription signed by your doctor.
Medicaid Rx Mail-Order Flier – Learn how to order the medicines that you take long-term or every day. You can have them delivered to your home.
Provider Form for Transportation Attendant – Use this form if you want to bring someone with you on a trip to/from an appointment. Your doctor will need to confirm it is medically necessary for an escort to go with you. This form must be sent in before you arrange to bring someone with you. Your doctor can fax the completed form to 1-866-402-0522.
Member Appeal Request Form – You or your appointed representative may use this form to file an appeal. Please see the instructions on the form to learn how to file an appeal.
Provider Appeal Request Form – You can have your provider submit an appeal for you. Use this form and please follow the instructions. Your provider will need to include certain information to support the request. Also, you must sign the form. Once completed, send it to the address shown on the form.
Power of Attorney Form – Have someone you trust to make health care decisions if you are unable to do so. Follow instructions on the form.