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Claims & Reimbursement Forms

• 835 Request Form
  (PDF) (Word)
• CAP-MR/DD Supply/Equipment Receipt and Authorization Confirmation Form
  (PDF) (Word)
• CCIS User Assignment Request
  (PDF)
• Claims Resolution Inquiry
  (PDF) (Word)
• CMS-1500 (formerly HFCA-1500) Health Insurance Claim Form. Re-posted 2/16/07
  NOTE: this is a special PDF file that contains form fields you can fill in on screen, then print, save, or fax it. You MUST save this file to your own computer before using it, DO NOT fill it in online! This is not a secure website. If you fill it out online you will violate HIPAA privacy/security laws.
  (PDF)
• EFT Authorization Agreement
  (PDF) (Word)
• Medicaid Direct Enrolled Provider Billing Registration Application (04/02/08)
  (PDF) (Word)
• NPI Collection Form Oct 2010
  (Excel)
• State Funding Eligibility Statement 11/01/11
  (PDF) (Word)
• Trading Partner Agreement
  (PDF)

View All WHN Forms