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Administrative Forms and Notices

Appointment of Representative (Form CMS-1696)*

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Coverage Requests & Determination

Notice of Privacy Practices

Request for Claim Review Form

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Physician Peer-to-Peer Request Form

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Prior Authorization Forms

Esketamine Prior Authorization Request

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PA Form – Repetitive Transcranial Magnetic Stimulation Request (RI)

PA Form – Psychological & Neuropsychological Assessment (RI)

PA Form – Cardiac Imaging

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PA Form – CT/CTA/MRI

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PA Form – PET – PET CT

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Standard Prior Authorization Request Form

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CCA ECT Authorization Request

Claims Requirements

CMS Provider Directory Requirements

Guidance to Verify Adequate Networks & Current Provider Directories

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Provider Directory Requirements

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