Access Forms

Download important forms below.

Claim Forms

PDF icon Standard Medical Claim Form

PDF icon Standard Dental Claim Form

Appeal Forms

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

PDF icon Harvard Pilgrim Provider Appeal Form and Quick Reference Guide


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.

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 Bariatric Surgery

PDF icon Dental/Oral Surgery

PDF icon Pediatric/Adult Formula

PDF icon Implantable Neurostimulators

PDF icon Infertility Services

PDF icon Preimplantation Genetic Testing (PGT)

PDF icon Treatment of Varicose Veins

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