Provider Manual and Forms

Providers, use the forms below to work with AmeriHealth Caritas Pennsylvania Community HealthChoices.

Provider manual

• Download the provider manual (PDF)
• 2024 provider manual updates (PDF)

Provider forms

• Claims project submission form (PDF)
• Claim refund form (PDF)
• Enrollee consent form (PDF)
• Hospital acquired conditions (PDF)
• J&B Medical Incontinence Supply (PDF)
• Long-Term Services and Supports (LTSS) Provider Change Form (PDF)
• Medical Provider Change Form (PDF)
• Obstetrical Needs Assessment Form (PDF)
• Pennsylvania standard application (PDF)
• Pharmacy HCPCS prior authorization form (PDF)
• Pharmacy formulary addition/deletion/modification request form (PDF)
• Physician certification for an abortion (PDF)
• Recipient statement form (PDF)
• Serious reportable events in health care (PDF)
• Sterilization consent form (PDF)
• Time sheet documentation for manual EVV entries (PDF)
• W-9 form (PDF)

Prior authorization forms

• Chiropractic Request (PDF)
• Genetic Testing (PDF)
• Hospital Notification of Emergent Admissions (PDF)
• Outpatient Therapy/Cardiac or Pulmonary Rehab Request (PDF)
• Pain Management Injection Request (PDF)
• Prior Authorization Form (PDF)