Provider Forms

Provider Forms

Paperwork Made Easy

For your convenience, all the forms you need to participate in the CDPHP network can easily be downloaded to your computer.

• Online Access Forms
• Provider Secure Access Request Form
• 3rd Party Delegation Administration Form
• 3rd Party User Access Form

• General Forms
• Provider Review Form
• 837 Entity Information Request (EIR) Form
• 837 Transaction Companion Guide
• Access Information for 835 Transaction Set Form
• Access Standards for Primary Care Physicians and OB/GYNs
• High Risk Pregnancy Case Management Referral Form
• Outpatient Mental Health Treatment Report
• Outpatient Substance Abuse Treatment Report
• Patient Treatment Waiver - PCP or OB/GYN Visits
• Patient Treatment Waiver - Specialist Visits
• Provider Distribution Program - Order Form
• Physician' Academy Nomination Form
• Remittance Agent Designation

• Practitioner Credentialing and Maintenance Forms
• Practitioner Recred Forms Packet
• Practitioner Data Collection Form
• Physician Qualification Overview
• Qualification Requirements for Chiropractors, Dentists, and Podiatrists
• Qualification Requirements for Adjunct Practitioners
• Adjunct Practitioners Credentialing Application
• Practitioner Credentialing Application
• Statement of Practitioner's Rights
• Practitioner CAQH Application Instructions and Checklist
• W-9 Form
• Registration Form: Nurse Practitioner, Physician Assistant, Certified Nurse Midwife, Certified Genetic Counselor, and Locum Tenens

• Prescription Forms and Lists 
• CDPHP Clinical Formulary
• CDPHP Preferred Drug List
• CDPHP Three-tier Drug List
• Quantity Limits for Select Drugs
• Enteral Formula Request Form
• Excluded Drug List for Closed Formulary
• Medical Exception Request
• Medical Exception Request - COX-2 Inhibitor
• Medical Exception Request - Epogen/Procrit/Aranesp
• Medical Exception Request - Xenical/Meridia
• Medicare Choice with Part D Payor Sheet
• Medicare PPO with Part D Payor Sheet
• Medicare Drug Plans Formulary (4 Tier) - 2009
• Medicare Notice of Formulary Updates (4 Tier) - 2009
• Medicare Choices: Prior Authorization Drugs - Part B versus Part D 2009
• Medicare Choices: Prior Authorization Guidelines 2009
• Prescription Claim Form - Standard Claim
• Prescription Claim Form - Foreign Claim
• Prescription Claim Form - Medicare with Part D
• Prescription Mail Order Form
• Prescription Mail Order Form - Medicare with Part D
• Prior Authorization Form - Infertility Drugs

• Medical Record Forms 
• Health Maintenance Forms & NYS Department of Health Forms
• Diabetes Mellitus Flow Sheet
• Diabetes Eye Examination Report with Frequently Asked Questions
• DOH Sterilization Consent Form (LDSS-3134)
• DOH Acknowledgement Hysterectomy Information Form (LDSS-3113)
• DOH HIV Consent Form
• Health Care Proxy Form with Frequently Asked Questions
• Communicable Disease (STD) Reporting Requirements
• Communicable Disease Reporting Requirements
• Physician Letter - Reporting of Communicable Diseases
• STD Reporting Form
• STD Reporting Mandate
• Preventive Care Forms & Standards for Medical Record Documentation
• Adolescent Physical Exam Form: 11-18 yrs
• Adolescent Preventive Care Flow Sheet
• ADHD Screening Tool
• OB/GYN-Prenatal Risk Assessment Form and Definitions
• OB/GYN-Post Partum Progress Note
• OB/GYN-Annual GYN Exam Form
• OB/GYN Report to Primary Care Physician
• Pediatric Physical Exam and Development Sheet: 0-23 months
• Pediatric Physical Exam: 2-6 yrs
• Pediatric Physical Exam: 7-10 yrs

If you have any questions or need additional assistance, please contact CDPHP Provider Services.

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