Provider Forms

Forms related to processing or correcting a patient claim

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.

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.

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.

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