The forms listed on the menu below are for use by medical providers. These forms are in portable document format (PDF) and allow you to complete the form online, print, sign and mail to the appropriate address with supporting documents. Please contact your Network Development Representative at the Regional Office nearest you for assistance.

• Authorization Form for Clinic/Group Billing (PDF)
  Use for notification that a practitioner is joining a clinic or group.
  
  
• Exception Letter (PDF)
  Request a pre-service exception to receive network benefit reimbursement for non-network provider services. All requests are subject to medical necessity and coverage guidelines.
  
  
• New Clinic/Group Application (PDF)
  Use for NEW clinic or NEW billing group only. Not for current providers.
  
  
• Notice of Payer Policies and Procedures and Terms and Conditions (PDF)
  Applicable to all individual network participants and applicants.
  
  
• Pharmacy Prior Approval and Exception Request (PDF)
  
  
• Physician/Supplier Corrected Bill Submission Form (PDF)
  Use to correct a claim that USAble Administrators has already processed. You will need to furnish the claim number.
  
  
• Prior Authorization Form for Requested Services
  
  
• Provider Change of Data Form (PDF)
  Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
  
  
• Referral Form (PDF)
  Primary care physicians should use this form to refer a patient to a specialist when a referral is required by the patient's health plan.
  
  
• Termination Form for Clinic/Group Billing (PDF)
  Use for notification that a practitioner is leaving a clinic.
  
  

Forms for Dental Providers

• Accident Form for Dental Injury (PDF)
  
  
• Authorization Form for Clinic/Group Billing (PDF)
  Use for notification that a practitioner is joining a clinic or group.
  
  
• New Clinic/Group Application (PDF)
  Use for NEW clinic or NEW billing group only. Not for current providers.
  
  
• Provider Change of Data Form (PDF)
  Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
  
  
• Termination Form for Clinic/Group Billing (PDF)
  Use for notification that a practitioner is leaving a clinic.