Provider Forms

These forms are provided for your convenience, to facilitate various requests and administrative processes. Please complete and return forms as instructed.

• Prior Authorization Form
  Use this form when requesting prior authorizations and providing a supporting statement for an exception request.
  
  
• Sterilization Consent Form
  To receive reimbursement for sterilization procedures, please submit completed form and associated claim(s), according to Affinity guidelines, to:
  
  Claims Department
  Gracie Station
  229 E. 85th Street;
  PO Box 811
  New York, New York 11028
  
  You may also access this form from the New York State Department of Health’s website - http://www.health.state.ny.us/health_care/medicaid/publications/ldssforms.htm.
  
  
• Acknowledgement of Receipt of Hysterectomy Information Form
  To receive reimbursement for hysterectomy procedures, please submit completed form and associated claim(s), according to Affinity guidelines, to:
  
  Claims Department
  Gracie Station
  229 E. 85th Street
  PO Box 811
  New York, New York 11028
  
  You may also access this form from the New York State Department of Health’s website - http://www.health.state.ny.us/health_care/medicaid/publications/ldssforms.htm.



• Chronic Care Improvement Program Referral & Treatment Plan Form.
If you would like to refer an Affinity Member to our Chronic Care Improvement Program, please complete and return the form as instructed.

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