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 for processing/correcting a patient claim and appeals

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.

Appeals form
Sample form template for the exchange of information between medical and behavioral health providers. Please note we're now using a single appeals fax number: (425) 918-5592. This number is noted on the appeals form. Please make a note of it for your provider office.

Prior authorization, care management

Forms for 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.

Behavioral health exchange of information

Other frequently used forms

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