Forms and information
This page contains Culinary Health Fund forms and information for medical providers. If you are not able to find what you need, call Provider Services at 702-892-7313.
Tools
When your patients...
Medical help and services
Women's health
Medicine and prescriptions
Dental information
Eligibility, claims, and payments
Forms
- Accident inquiry formDownload PDF
- Acupuncture surveyDownload PDF
- Address change formDownload PDF
- Additional information formDownload PDF
- Alternate other health insurance (OHI) verification formDownload PDF
- Authorization for the release of protected health information (PHI)Download PDF
- Culinary Health Center Authorization Form for the Release of Protected Health InformationDownload PDF
- Diabetic test strips and lancets refill formDownload PDF
- Group add request formDownload PDF
- Health insurance verification formDownload PDF
- Initial credentialing application formDownload PDF
- Loss of time form and checklistDownload PDF
- NHS prior authorization formDownload PDF
- OptumRx prior authorization formDownload PDF
- Pregnancy notification formDownload PDF
- Reconsiderations formDownload PDF
- Recredentialing applicationDownload PDF
- Repayment agreement formsDownload PDF
- Sleep study pre-screening and Epworth sleepiness scale form
- Sleep study referral formDownload PDF
- Smoking cessation program referral formDownload PDF
- Statement of facts formDownload PDF
- Subrogation forms packetDownload PDF
- Vacepa prior authorization request formDownload PDF