PROVIDER FORMS

CVS Specialty Referral Form

Appointment of Representative (Group Members)

Appointment of Representative (Medicare Members)

Authorization Request Fax Form

Credentialing Application

Directory Information Change Form

Hospital Authorization Request

Hospital Resource Form

Request to Reopen a Medicare Adverse Determination

NPI Provider Notification Form

AvMed Verification Form

NIA-RadMD Imaging Provider Handbook

NIA-RadMD Benefits

NIA-RadMD Quick start Guide

Care Opportunity Response Form

Co-Ordination of Benefits Claim Form

Provider Interest Form

Request for Claim Review / Appeal

Request for Claim Status

On Call Relationship

Instruction on Billing Additional Codes

PCP-Behavioral Health Coordination Form

NCH Cardiology Matrix

NCH Cardiology FAQs

Medical Oncology & Hematology Prior Authorization Matrix

Medication Exception Request Form (Commercial)

Medication Exception Request Form (Medicare)

Waiver of Liability for AvMed Medicare Non-Participating Providers

Notice of Medicare Non-Coverage Form

Notice of Medicare Non-Coverage Form (Spanish)

Transition of Medication Form

CVS Specialty Drug List - January 2021

Specialty Medication Dis-Enrollment Form

CVS Specialty Medication Delivery Program Form