Maryland Physician Care

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Forms

Whether you need to make a referral, request prior authorization for a treatment or more, filling out the necessary forms will help us respond to your needs quickly and efficiently. Just click on the appropriate form name below to get started.

General Provider Forms

  • Electronic Remittance Advice/835
  • Maryland Uniform Consultation Referral Form
  • Maryland Uniform Credentialing Form
  • W-9 Form
  • Maryland Healthy Kids/EPSDT Provider Application for Certification
  • Provider Verification Form
  • Medical Prior Authorization Request Form
  • Prior Authorization Retro Lab or Radiology Form
  • Suboxone/Subutext Notification Form
  • Pharmacy Prior Authorization Forms
  • Provider Web Portal Registration Form
  • Electronic Funds Transfer Form

Well Child Visit Forms

  • Pediatric Visit 0 to 1 Month Form
  • Pediatric Visit 2 to 3 Months Form
  • Pediatric Visit 4 to 5 Months Form
  • Pediatric Visit 6 to 8 Months Form
  • Pediatric Visit 9 to 11 Months Form
  • Pediatric Visit 12 to 14 Months Form
  • Pediatric Visit 15 to 17 Months Form
  • Pediatric Visit 18 to 23 Months Form
  • Pediatric Visit 2 Years Form
  • Pediatric Visit 3 Years Form
  • Pediatric Visit 4 to 5 Years Form
  • Pediatric Visit 6 to 11 Years Form
  • Pediatric Visit 12 to 13 Years Form
  • Pediatric Visit 14 to 16 Years Form
  • Pediatric Visit 17 to 20 Years Form

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Check the status of a claim, find a doctor and more on our secure site.

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  • Prior Authorization
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  • Fraud & Abuse
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    Toll-free: 1-800-953-8854
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    MEMBER HAS A MEDICAL EMERGENCY, CALL 9-1-1