Provider Forms

For your convenience, we've categorized our most frequently used forms. If you can't find the form you need or require further assistance, please contact us.

Claims, billing, appeals

Forms related to processing or correcting a patient claim

Appeal authorization form
When submitting an appeal on behalf of a member, include this form signed by the member authorizing release of healthcare information and records.

Balance billing protection act dispute form
Providers or facilities not contracted with LifeWise can use this form to submit a balance billing dispute request. The form must be received by LifeWise within 30 calendar days from receipt of the original payment notification. Find out more about the Balance Billing Protection Act.

Corrected claim cover sheet
Use this form to correct billing information on a previously processed claim.

Other coverage questionnaire enrollment
Use this form to provide information about other healthcare coverage a patient may have.

Overpayment notification form
Use this form to notify LifeWise of an overpayment your office received.

Support document cover sheet
Use this form to submit supporting documentation that is required to process a claim.

Prior authorization, care management

Forms related to prior authorization, requesting medical necessity reviews, or case management referrals.

Out-of-network exception request

Admission notification

Prior authorization request

Durable medical equipment
Use this form to verify if DME is medically necessary.

Miscellaneous

Other frequently used forms

Confidential Exchange of Information Form
Sample form template for the exchange of information between medical and behavioral health providers.

Dental Insurance Verification
Use this form as a template for documenting dental benefits when calling customer service for a dental benefit quote.

Internal Revenue Service

W-9
Use this form to provide LifeWise with your current Taxpayer Identification Number (TIN) information.