Provider Forms

Provider Forms

Paperwork Made Easy

For your convenience, all the forms you need to participate in the CDPHP network can easily be downloaded to your computer.

If you have any questions or need additional assistance, please contact CDPHP Provider Services.

• General Forms
• Provider Review Form
• Provider Online Access Checklist
• Online Health - Add or Modify a User for a Physician Office or Hospital
• Online Health - Add a New Physician Office or Hospital
• Online Health - 3rd Party Delegation Request Form
• 837 Entity Information Request (EIR) Form
• Access Information for 835 Transaction Set Form
• Access Standards for Primary Care Physicians and OB/GYNs
• High Risk Pregnancy Case Management Referral Form
• Patient Treatment Waiver - PCP or OB/GYN Visits
• Patient Treatment Waiver - Specialist Visits
• Provider Distribution Program - Order Form
• Physician' Academy Nomination Form
• Referral Authorization Reorder Form
• Remittance Agent Designation

• Practitioner Credentialing and Maintenance Forms
• Practitioner Data Collection Form
• Physician Qualification Overview
• Qualification Requirements for Chiropractors, Dentists, and Podiatrists
• Statement of Practitioner's Rights
• Practitioner CAQH Application Instructions and Checklist
• Adjunct Practitioner Credentialing Application
• W-9 Form
• Registration Form: Nurse Practitioner, Physician Assistant, Certified Nurse Midwife, Certified Genetic Counselor, and Locum Tenens

• Prescription Forms and Lists 
• CDPHP Clinical Formulary
• CDPHP Preferred Drug List
• CDPHP Three-tier Drug List
• Quantity Limits for Select Drugs
• Enteral Formula Request Form
• Excluded Drug List for Closed Formulary
• Medical Exception Request
• Medical Exception Request - COX-2 Inhibitor
• Medical Exception Request - Epogen/Procrit/Aranesp
• Medical Exception Request - Xenical/Meridia
• Medicare Choice with Part D Payor Sheet
• Medicare PPO with Part D Payor Sheet
• Medicare Drug Plans Formulary - 2008
• Medicare Notice of Formulary Updates
• Prescription Claim Form - Standard Claim
• Prescription Claim Form - Foreign Claim
• Prescription Claim Form - Medicare with Part D
• Prescription Mail Order Form
• Prescription Mail Order Form - Medicare with Part D
• Prior Authorization Form - Infertility Drugs

• Medical Record Forms 
• Health Maintenance Forms & NYS Department of Health Forms
• Diabetes Mellitus Flow Sheet
• Diabetes Eye Examination Report with Frequently Asked Questions
• DOH Sterilization Consent Form (LDSS-3134)
• DOH Acknowledgement Hysterectomy Information Form (LDSS-3113)
• DOH HIV Consent Form
• Health Care Proxy Form with Frequently Asked Questions
• Preventive Care Forms & Standards for Medical Record Documentation
• Adolescent Physical Exam Form: 11-18 yrs
• Adolescent Preventive Care Flow Sheet
• ADHD Screening Tool
• OB/GYN-Prenatal Risk Assessment Form and Definitions
• OB/GYN-Post Partum Progress Note
• OB/GYN-Annual GYN Exam Form
• OB/GYN Report to Primary Care Physician
• Pediatric Physical Exam and Development Sheet: 0-23 months
• Pediatric Physical Exam: 2-6 yrs
• Pediatric Physical Exam: 7-10 yrs

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