Forms and resources for non-participating providers
Information and forms for providers who are not part of the Geisinger Health Plan provider network
- Outpatient Rehab Precert Form
- Inpatient Rehab Precert Form
- Outpatient Prior Authorization Request Form
- DME Initial Precert Form
- Formulary Exception/Prior Authorization Request Form
- Subutex®/Suboxone® Prior Authorization Request Form
- Specialty Drug List – GHP Family
- Specialty Vendor Drug List
- Hepatitis C Virus Direct-Acting Antivirals Prior Authorization Request Form
- ≤ 17 Years Old Antipsychotic Authorization Request Form
- LA Atypical Antipsychotic Request Form
- Gold Nonpar Provider Appeal Process Form
- Erythropoietin Stimulating Agents (ESA) Request Form
- Opioid Cumulative Morphine Equivalent Dose (MED) Prior Authorization Form - For Medicare
- Opioid Use Prior Auth Form - For Medicaid
- Opioid Use Prior Auth Form - For Commercial, Marketplace and TPA
- Home Health Services Request Form
Learn more about Geisinger Health Plan.
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If you have questions or need more information, contact Geisinger Health Plan.
Terms and conditions
View GHP’s terms and conditions.