Access common forms that you need to do business with CoOportunity Health from this central location.
- Home Health Care Prior Authorization
- Hospice Communication Form
- Hospital Admission/Discharge Notification Form
Skilled Nursing Facility
- Skilled Nursing Facility Admission Prior Authorization Form
- Continued SNF Stay Request for Authorization
Behavioral Health
- Hospital Admission/Discharge Notification Form
- For residential behavioral health admissions, see Behavioral Health tab above
To refer a patient to our Care Management program, complete the Clinical Program Referral Form.
Access to Care Management Programs:
Prior Authorization Requests:
- Chemical Health Authorization Request Form for Residential Level of Care
- Chemical Health Residential Level of Care Continued Service Request Form
- Continued Outpatient Treatment Request Form for Out of Network Providers and Required Prior Authorization Services
- Eating Disorder Intensive Program Authorization Request Form
- Eating Disorder Request Form - Residential
- In-Home Therapy Request Form - Initial Request ONLY
- Neuropsychological and Psychological Testing Request Form
- Pain Program Prior Authorization Form
- Residential Treatment Concurrent Review Request Form
- Residential Treatment Initial Request Form
Access to Care Management Programs:
Common Prior Authorization Request Forms
- Air Fluidized Specialty Bed Group III - DME Request Form
- Airway Clearance System/Chest Compression Generator System - Prior Authorization Form
- BRCA Genetic Review Form
- Breast Pump Review Form
- Bronchial Thermoplasty - Prior Authorization Form
- Cognitive Rehabilitation - Prior Authorization Form
- Continuous Glucose Monitor - DME Request Form
- Continuous Passive Motion (CPM) Review Form
- Durable Medical Equipment (DME) CLINIC Prior Authorization Form
- Durable Medical Equipment (DME) VENDOR Prior Authorization Form
- Enteral Nutrition (Formula) Review Form
- Epidural Steroid Injection Medical Review Form
- Habilitative Therapy (PT, OT, Speech) Review Form
- Home Health Care Prior Authorization
- Hospice Vendor Communication Form
- Hospital Bed Review Form
- Implantable Spinal Cord Stimulator (SCS) for Treatment of Neuropathic Pain Medical Review Form
- Lift Chair Review Form
- Medical Dental Procedure Review Form
- Mobility Assistive Equipment (MAE)
- Neuromuscular Electrical Stimulator Review Form
- Oral Appliance - Medical Necessity DME Medical Review Form
- Out-of-Network Exception Request Form
- Pharmacy Prior Authorization Exception Form
- Prior Authorization Form for Procedures
- PT / OT Rehabilitation Review Form
- Radiofrequency Ablation Spine Review Form
- Sacroiliac Injections Form
- Sclerotherapy Review Form
- Specialty Mattress Overlay Group I or Group II Review Form
- Specialty Mattress Group III Review Form
- Spinal Fusion, Lumbar, Medical Review Form
- Synagis (RSV) Season Review Form
- Transplant Medical Review Form
- Weight Loss Surgery Referral Checklist