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Health Care Provider Forms

ENCOMPASS offers health care providers online forms as an easy way to contact us regarding a service need. You can also contact ENCOMPASS by calling the toll-free phone number on a member's health plan identification card.

To use an online form, select from the following:

• Prior Authorization Request Form
  Health care providers may use this form to request a medical review and submit clinical information.

• Clinical Information
  Health care providers may use this form to submit updated clinical information for an existing case.

• Physical Therapy Initiation Form
  Health care providers may use this form to begin a physical therapy review.

• Notification for Golden Rule
  Health care providers may use this form for Golden Rule Insurance Company notification requirements.

• Network Customer Service Request Form
  Health care providers may use this form to submit an ENCOMPASS network customer service inquiry.

• Baxter Referral Form
  Health care providers may use this Primary Care Network (PCN) Physician Referral Authorization Form for Baxter health plan members.

• Contact Us
  Use this form to submit general questions, concerns, inquiries, or requests related to ENCOMPASS or our services.