Provider Forms

Case Management

• Case Management Referral Form
• Certificate of Medical Necessity — Blank
• Certificate of Medical Necessity — TENS

Claims

• Request for Claim Review Form and Instructions (This form is not to be used for Level of Care Request for Review.)
• Medicare Preventive Services Educational Tool
• Provider Remit Appeal Review Rights
• Waiver of Liability Statement
• Medical Director Form
• Skilled Nursing Facility Immunization Billing
• ADA Dental Claim Form
• EFT-ERA Enrollment Form

Compliance

• FDR Attestation Form
• FDR Offshore Subcontractor Attestation

Network Providers

• Provider Information Change Form
• Provider Request for Termination Form

Prescription Drugs

• Request for Medicare Prescription Drug Coverage Determination. Use this form to request a coverage determination or exception to MediGold’s drug formulary.
• Request for Redetermination of Medicare Prescription Drug Denial. Use this form to file an appeal related to your Part D prescription drug benefits.
• Part D Authorization Forms

Utilization Management

• Hospital Admission Notification form
• Request for Post-Discharge Review

Prior Authorization

• Prior Authorization Request Form
• Prior Authorization Request Form (Part B Drugs)
• Inpatient Rehabilitation and Long-Term Acute Care (IPRH)
• Power Mobility Device Questionnaire (Must be completed in addition to Prior Authorization Request Form.)

Skilled Nursing Facilities

• Request to Discontinue Skilled Services
• SNF Admission Notification form
• SNF Update form

This page was last updated 10/14/2026