The forms listed on the menu below are for use by medical providers. These forms are in portable document format (PDF) and allow you to complete the form online, print, sign and mail to the appropriate address with supporting documents. Please contact your Network Development Representative at the Regional Office nearest you for assistance.

• Authorization Form for Clinic/Group Billing (PDF): Use for notification that a practitioner is joining a clinic or group.
  
  
• Exception Letter (PDF): Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines.
  
  
• Notice of Payer Policies and Procedures and Terms and Conditions (PDF): Applicable to all individual network participants and applicants.
  
  
• Pharmacy Forms for Medications that have Quantity Limits
  
  
• Physician/Supplier Corrected Bill Submission Form (PDF): Use to correct a claim that USAble Administrators has already processed. You will need to furnish the claim number.
  
  
• Provider Change of Data Form (PDF): Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
  
  
• Referral Form (PDF): Primary care physicians should use this form to refer a patient to a specialist when a referral is required by the patient's health plan.
  
  
• Termination Form for Clinic/Group Billing (PDF): Use for notification that a practitioner is leaving a clinic.
  
  

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