Text Size

Marketplace Premium Payment 1-888-518-7597
Individual & Group Coverage: (800) 400-PCHP
Medicare Advantage: (877) 210-1719
TTY: 711

 

 

 

Provider Forms

As a valued Piedmont Provider, our goal is to assist you in serving or members.  To that end, participating providers can download printable Provider Forms by clicking on the following links: 

  •   CLICK HERE for the CPAP Authorization Request Guide
  •   CLICK HERE for the DME Request Fax Form
  •   CLICK HERE for the Referral Authorization Request
  •   CLICK HERE  for the Network Participation Request Form (Credentialing for individual physicians/practioners)
  •   CLICK HERE  for the Network Participation Update Form (Individual provider)
  •   CLICK HERE  for the Network Participation Request Form (Organizational Provider)
  •   CLICK HERE for the Appeal Request Form