Health Plans General Provider Appeal form (non HPHC)

Harvard Pilgrim Provider Appeal form and Quick Reference Guide

Standard Medical Claim form

Standard Dental Claim form

Please note: Prior authorization requirements vary by plan. Please contact HPI Provider Services or visit Access Patient Benefits to 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 will be returned.

Complete a Prior Authorization Request Online

Need to fax your form? Download forms below:

Download a Standard Prior Authorization Request form

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.

Chemotherapy/Cancer Treatment Medication 
Chemotherapy Support Drugs 

Pediatric/Adult Formula

Infertility Services