Provider Forms

Non-Contracted Providers

• Non-Contracted Facility Information Form
• W-9
• NPI/UMPI Notification Form
• Electronic Remittance Advice (ERA) Agreement
• Electronic Funds Transfer (EFT) Agreement
• Non-Contracted Provider Address Change Form
• Participation Request Form
• Waiver of Liability Statement
• Web Portal Registration Form

Contracted Providers

• Facility Change/Update Form
• W-9
• Electronic Remittance Advice (ERA) Agreement
• Electronic Funds Transfer (EFT) Agreement
• Disclosure of Ownership and Control Interest Statement
• Web Portal Registration Form
• Contracting Forms
• Credentialing Forms (for contracted providers)

Claims

• Adjustment Request Form
• Claim Attachment Cover Sheet (AUC) Form
• PrimeWest Health Error Numbers and Descriptions

Pharmacy

• Formulary Exception Forms

Updated_04/02/2024