Forms

When you’re in need of a standard Fallon Health form, this is the place. The forms most frequently needed by Fallon providers are listed below.

• OB/GYN Provider Attestation Form - Fallon ACO plans only (pdf)
• Caremark Mail Order Form (pdf)
• Caremark Specialty Pharmacy Form (pdf)
• Case Management Referral Form (pdf)
• Disease Management Referral Form  (pdf)
• Health Insurance Claim Form (pdf)
• Infertility Services Prior Authorization Request Form (pdf)
• Material Request Form
• MCE Behavioral Health Provider/Primary Care Provider Communication Form (pdf)
• NaviCare HMO SNP and SCO Oral Nutritional Supplements: Medical necessity review and prescription (pdf)
• PCP selection/change form (pdf) New!
• Pharmacy Prior Authorization Forms
• Plan Determination Form (pdf)
• Provider Update Form 
• Request for Claim Review Form and Reference Guide 
• Safe Transitions Referral Form (pdf) New!
• Skilled Nursing Facility Admission Review Request (pdf)
• Skilled Nursing Facility Request for Continued Stay Form (pdf)
• Special Formula Medical Necessity Form (pdf)
• Standardized Prior Authorization Request Form (for non-pharmacy PAs)
• Third Party Liability Indicator Form (pdf)
• Universal Health Plan/Home Health Authorization Form (pdf) 
   

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