Materials and Resources


To send requested documents to Provider Services via fax, please fax back to 1­-312­-724-9256 or send back via email to [email protected].

The following resources can help you with our processes and procedures:

Patient Centered Medical Home (PCMH) list
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Provider Services Manual
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Provider Services Quick Resource Guide
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Ambulance Service Providers
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Claims “Cheat Sheet”
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Claims Dispute Form
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Request for Inpatient Prior Authorization Form
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Request for Outpatient Prior Authorization Form
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Request for Behavioral Health Prior Authorization Form
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NextLevel Health Provider Inquiry Form
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NextLevel Health CI Intake Form
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NextLevel Health Pharmacy Prior Authorization Form
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NextLevel Health Drug Formulary
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HEDIS 2018/2019 Reference Guide
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Attestation of Training Completion Form
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IRS W-9 Form
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DASA and Behavioral Health Services Authorization Update
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HFS 2270 Physician Certification Statement (PCS) for Ambulance Transport (pdf)
Requires Adobe Reader
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Educational Information and Links:

Americans with Disabilities Act
You are required to comply with the Americans with Disabilities Act (ADA), which ensures medical services are accessible for all individuals (Click Here).