Effective July 1, 2024

Use the forms on this page as needed in your care of IBHP members. You will need to download and install Adobe Acrobat Reader to use the PDF forms.

• Ad Hoc/Out-of-Network Provider Request Form (Word download)
• Claim Dispute Form (online form)
• Concurrent Review Form (Word download)
• Critical Incident Report Form (online form)
• Discharge Information Form (Word download)
• Initial Request for Inpatient Care Form (Word download)
• Intensive Care Coordination Program Referral Form English Spanish (pdf)
• Member Authorization for Use and Disclosure of/Consent to Release Protected Health Information (PHI)
  • English instructions (pdf)
  • English form (pdf)
  • Spanish instructions (pdf)
  • Spanish form (pdf)
• Outpatient Care Authorization Request Form (Word download)
• Psychiatric Residential Treatment Facility Preauthorization Form (Word download)
• Psychological Testing Preauthorization Request Form (Word download)

Additional forms to come