Here you'll find our most frequently used forms. If you can't find the form you need, please contact us.
Claim form - Need to file a claim? Start here
FSA/HRA expense manual claim form - Get reimbursed for eligible out-of-pocket medical expenses if you have a flexible spending account (FSA) or a health reimbursement arrangement (HRA).
HSA expense manual claim form - Get reimbursed for qualified out-of-pocket medical expenses if you have a health savings account (HSA).
Incident questionnaire - Complete this form after sustaining an injury or being involved in an accident.
Dependent care account claim form
Other coverage questionnaire - Complete this form to provide information about other coverage you may have.
Discount card reimbursement - Get reimbursement for your prescription costs if you are a member of the Affordable Care Act's Drug Discount Program.
Prescription drug reimbursement - Apply for reimbursement of your prescription costs.
Express Scripts mail-order form - Want your prescription drugs delivered directly to you at home? Use this form.
Health, allergy & medication questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Authorization for release of psychotherapy notes - Allow access to notes made by medical professionals providing psychiatric or psychological services.
Disclosure accounting request - Request a record of how we disclose information about you for reasons other than our normal business functions.
Information release form - Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. You can also authorize members on your plan to see your sensitive information on LifeWiseWA.com or ConnectYourCare (medical funding account).
Non-disclosure request form - Tell us your requests concerning sharing your health information.
Request for amendment of records - Change your official personal information we maintain using this form.
Request for inspection of records - Request certain records that we maintain containing your personal information.
Appeal submission form with authorization - Resolve billing issues that directly impact payment or a write-off amount. Member authorization is embedded in the form for non-contracted providers. See section C.
Complaint and appeal rights - Learn about your appeal rights.
Form for requesting medical necessity reviews or case management referrals.
Admission and discharge notification
Pre-service and prior authorization review request
Request forms to verify if a service is medically necessary.
General prior authorization request
Out-of-network exception request - For out-of-network providers to request in-network benefits applied to their service.
Durable medical equipment (DME)
Claims, billing, appeals
Appeal authorization form - When submitting an appeal on behalf of a member, include this form (signed by the member) authorizing release of healthcare information and
Corrected claim cover sheet - Correct billing information
on a previously processed claim.
Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident.
Massage therapy prescription submission form - Request coverage of massage therapy services.
Overpayment notification form - Notify LifeWise of an overpayment your office received.
Standard provider letter for refunds under $25 - Use this form to document refunds under $25. (We don't send letters requesting a refund for overpayments
of less than $25 per claim.)
Policy reconsideration form - Request reconsideration of a coding policy.
Supporting documentation cover sheet - Submit
supporting documentation required to process a claim.
Forms for applying to our network or making changes to your current information.
Important: Many Washington counties are closed to accepting new providers. Check the Washington Network Closure Matrix before applying.
LifeWise uses ProviderSource™ to manage data for credentialing, recredentialing, and privileging. ProviderSource is a free service and requires:
Note: Washington House Bill 2335 went into effect on June 1, 2018, and requires the following:
Practitioner credentialing/recredentialing addendum - Provide LifeWise with the practitioner's medical record retrieval and
W-9 - Provide us with your current taxpayer identification number (TIN).
Organization/facility credentialing/recredentialing application - To join our provider network as a facility, complete this application and a W-9 form. Email us your completed documents. The credentialing process typically takes 60-90 days. Acceptance is based on your application information and network requirements. If your submitted application is accepted, you'll receive a contract to review and sign. Once you return your signed contract, you’ll receive a counter-signed contract and the effective date of your participation.
Dental provider credentialing application
Learn about our pharmacy programs and find pharmacy forms that require prior authorization.
learn about electronic funds transfer
check eligibility & benefits
submit prior authorization
look up claim status
search medical policies
search payment policies
view patient decision aids