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

Prior Authorization Forms

Please note: Prior authorization requirements vary by plan. Please contact HPI Provider Services or log in to Access Patient Benefits and review your patient's plan description for a full list of services requiring prior authorization. Prior authorization forms below are only for plans using AchieveHealth™ CMS. Please verify the correct prior authorization vendor prior to submitting forms; unverified prior authorizations wil be returned.

PDF icon Standard Prior Authorization Request

If your patient's plan requires Prior Authorization for a service or procedure listed below, please complete the Standard Prior Authorization 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

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