Forms

When you’re in need of a standard FCHP form, this is the place. The forms most frequently needed by FCHP providers are listed below—simply click, download and print!

• Health Insurance Claim Form (pdf, 272 KB)
• Material Request Form
• Infertility Services Pre-Authorization Request Form (Medical and Pharmacy) (pdf, 146 KB)
• Outpatient Care Services Referral Form (pdf, 44 KB)
• PharmaCare Pharmacy Form (pdf, 31 KB)
• Plan Determination Form (pdf, 912 KB)
• Prior Authorization Prescription Form (pdf, 24 KB)
• Provider Claims Adjustment Request Form (pdf, 35 KB)
• Provider Appeals Request Form (pdf, 61 KB)
• Request for Preauthorization Form (pdf, 60 KB)
• Skilled Nursing Facility Admission Form (pdf, 442 KB)
• Skilled Nursing Facility Request for Continued Stay Form (pdf, 451 KB)
• Universal Health Plan/Home Health Authorization Form (pdf, 112 KB) 
   

Is there an additional form or two you would like listed here? Let us know!