Member Handbook, Provider Directory, Preferred Drug List, Forms, and Policies

Here are links to the manuals, forms, and policies available to you.

Manuals

• Member Handbook - English (PDF)
• Member Handbook - Spanish (PDF)
• Preferred Drug List

Provider Directory

• Region 3 Provider Directory (PDF) - Updated September 2022
• Region 4 Provider Directory (PDF) - Updated September 2022
• Region 5 Provider Directory (PDF) - Updated September 2022

Member Forms

• Designation of Authorized Representative Form (PDF)
• Authorization to Use and Disclose Health Information (PDF)
• Revocation of Authorization to Use and/or Disclose Health Information (PDF)
• Request for Amendment of Health Information (PDF)
• Request for Accounting of Disclosures of Health Information (PDF)
• Request for Restrictions on Use and Disclosure of Health Information (PDF)
• Request for Accessing/Inspecting/Copying Health Information (PDF)

Policies

• Utilization Management Policy (PDF)
• Opioid Misuse Prevention Pharmacy Lock-In Policy (PDF)
• In Lieu of Services (ILOS) Policy (PDF)
• Good Faith Provider Policy (PDF)
• Pharmacy Services Clinical Coverage Policies

Pregnancy Forms

• Notification of Pregnancy (NOP) Form (PDF)

Privacy Practices

• Notice of Privacy Practices – English/Spanish (PDF)

Value-Added Services Forms

• Over-the-Counter Health and Wellness Catalog (PDF)
• WW Program Physician Referral Form (PDF) 
• YMCA Diabetes Prevention Program and Blood Pressure Self-Monitoring Program (BPSM) Physician Referral Form (PDF)
• New Mother's Package Online Web Form
• After School/Youth Organization Online Web Form
• Educational Support Online Web Form
  • Educational Tutoring Services Member Authorization Form (PDF)