Access Forms

Download important forms below.

Referral Portal Access

PDF icon Referral Portal Access Form

Referral Form

PDF icon Referral Form


PDF icon Health Plans General Provider Appeal Form (non HPHC)

PDF icon Harvard Pilgrim Provider Appeal Form and Quick Reference Guide


PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form


Precertification Requests 

Precertification vendors and requirements vary by plan. Please call the Provider Services or Precertification phone number on your patient’s member ID card or visit Access Patient Benefits to determine where to send your precertification request and to review your patient's plan description for a full list of services requiring precertification.

Precertification completed by HPI AchieveHealth® CMS

Precertification forms below are only for plans using AchieveHealth CMS in New England and Halifax. Please verify the correct precertification vendor prior to submitting forms; unverified precertifications will be returned.

AchieveHealth Precertification List

Complete a Precertification Request Online

Need to fax your form?

Download a Precertification Request form* (unverified requests may not be processed)

*If your patient's plan requires Precertification for a service or procedure listed below, please complete the Standard Precertification Request form in addition to the applicable form below.

PDF icon Chemotherapy/Cancer Treatment Medication

PDF icon Chemotherapy Support Drugs

PDF icon Pediatric/Adult Formula

PDF icon Infertility Services


Precertification completed by MedWatch

Complete a Precertification Request Online

Call: 877-532-5220


Precertification for Genetic Testing

Effective June 1, 2024, precertification for genetic and molecular diagnostic testing is delegated by HPI to Carelon Medical Benefits Management (Carelon). The Plan requires providers to obtain precertification for genetic and molecular testing; the delegation of Utilization Management (UM) to Carelon, a URAC accredited company, is for members of HPI when CMS administers UM. Ordering providers should contact Carelon to request clinical appropriateness review and obtain a precertification before scheduling or performing any genetic testing services. Ordering providers may submit precertification requests online 24/7 at or by calling Carelon toll-free at 833-607-1729, Monday through Friday, 8am to 5pm ET.

Carelon Genetic Testing Resource Site 

Carelon Genetic Testing Guidelines


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