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Forms Index

 

Forms can be completed directly on your computer and printed for faxing or mailing to HMSA.

 

The first column of the table below contains links to documents that describe or otherwise refer to the listed forms. The second column contains links to the actual forms.

 

Description, Instructions or Other Information Link to Form Provider Type
ABA Facility Program Initial Application & Checklist Form  
Access Request and Contract to Preserve Confidential Information Form Form Multiple
Affordable Care Act (ACA) Fax Order Form for Women's Preventive Health Services Materials Form Multiple
Adult Care Material Order Form Form  
Agent Authorization

Form

Multiple
Agreement of Financial Responsibility - Medical

Form

eSignature Form

Multiple
Akamai Advantage Annual Wellness Visit Form Form Multiple
Akamai Advantage Non-Contracted Provider Appeal and Payment Dispute Request Form Multiple
Akamai Advantage Non-Contracted Provider Waiver of Liability Statement Form Multiple
Appealing a Pre-certification Denial

Form

Multiple
Appealing Processed Claims

Form

Multiple
Applied Behavior Analysis (ABA) Precertification Request Form Form  
Apply to HMSA Forms Provider Enrollment
Asthma Quality of Life Measures Survey (for Xolair)

Form

Medical
Authorization of Release of Records or Information (no instructions available)

Form

Behavioral Health
Business Associate Authorization Form Form Multiple
Behavioral Health Facility/Program Credentialing Document Checklist and Application Form (Addendum) Form  
Bone (Mineral) Density Studies

Form

Medical
Breast Tomosynthesis Waiver Form Medical
CAAP - Care Access Assistance Program Instructions Instructions Medical
CAAP - Care Access Assistance Program Form

Form

Medical
CAAP - Carpenters' Mainland Travel Request Form (no instructions available)

Form

Medical
Care Denial Letter

Form

Home Health
Care Model - HMSA Integrated Service Center Referral Form  
Change to HHIN Provider List Form Form  
CMS 1500 - Interactive (instructions incorporated into form)

Form (version 02-12)

Multiple
Confidential Communications for Minors (no instructions available)

Form

Multiple
Coordination of Benefits (COB) Subscriber Questionnaire (no instructions available)

Form

Multiple
Detailed Explanation of Noncoverage

Form (MS Word)

Form (PDF)

Multiple
Detailed Notice of Discharge

Form (MS Word)

Form (PDF)

Facility
Disclosure of Information Required for Participating with HMSA QUEST

Form (PDF)

Multiple
Documentation Necessary for Continuation of Oxygen Form (PDF) Multiple
Documentation Worksheet

Form (PDF)

Multiple
Drug Review Request

Form

Medical
Electronic Funds Transfer

Hardcopy Form

Online Form

Instructions

Medical
Electronic Remittance Advice

Form

Instructions

Medical
Electronic Trading Partner Agreement Form Multiple
E/M Worksheet

Form (PDF)

Multiple
Form 97 - Unable to Process Claims Form (PDF) Multiple
HMO Administrative Review (Same as pre-certification general form) Form Multiple
HMSA Hepatitis C Treatment Checklist Form (PDF) Medical
HMSA Member Agreement of Financial Responsibility Form (PDF) Medical
HMSA QUEST Integration Referral Form

Form

Medical
HPH/HMO Travel Registry Form

Form

Multiple
HSTA Travel Assistance Reimbursement Request From Form Multiple
Important Message from Medicare

Form (MS Word)

Form (PDF)

Facility
Injury/Illness Report Form

Form

Multiple
Integrated Denial Notice (Notice of Denial of Medical Coverage, NDMC)

Form (MS Word)

Form (PDF)

Facility
IV Therapy Cover Sheet

Form

Home IV therapy
In-Vitro Fertilization

Form

Medical
Mail Order Prescription Drug Program

Form

Medical
Medicare Advantage Non-Contracted Provider Waiver of Liability Statement

Form

Multiple
Member Requests for Confidential Communication - Minors - Substance Abuse/Family Planning

Form

Medical
Member Requests for Confidential Communication - Adults, Minors - Other Services

Form

Medical
Notice of Medicare Noncoverage (NOMNC)

Form (MS Word)

Form (PDF)

Facility
PCMH Level Verification Form Form (PDF) Medical
Pediatric Material Order Form Form (PDF) Medical
Physician Quality Recognition Survey Form (PDF) Medical
Precertification Request - Behavioral Health Services Form Facility

Precertification Request - General (no instructions available)

Use this form only if no other pre-certification request form applies.

Form

Medical
Precertification Request - Home IV Therapy

Form

Home IV therapy
Precertification Request - Post Acute Care Services Form Facility
Pre-implantation Genetic Diagnosis Precertification Form

Form

Medical
Physician Orders for Life-Sustaining Treatment (POLST)   Medical
Provider Patient Panel/PCP/Specialist Change Form

Provider (PDF)

Health Center (PDF)

HMO Health Center/Provider
Provider Information Forms

Address Change Form

Additional Location Form

Closed Location Form

Payment Change Form

 
QUEST Integration Service Coordination Referral Form Form  
Request for Fee Review

Form

Medical

Student's Health Record - FORM 14 

This is the official health record for all students in the public school system. FORM 14 contains the necessary requirements for 7th grade school entry. Every student is required to submit a health record upon entry into the 7th grade public school system.

Form  
UB-04 Claim Form - General Instructions

Form

Facility
Vaccine Additional Payment Request

Form

Medical
Well-Being Connection Physician Forms

HMSA Physician Form

Queens Physician Form

Medical

 

 

To view the previous version of this document, see Forms Index - OBSOLETE.

 

Latest Revision:05/10/2017
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