- Application for Duplicate Remittance Advice (RA) Statement
- Appointment of Representative (AOR) Form
- Claim Adjustments
- Claim Form Finder – New! Updated January 6, 2023
- Claim Reconsideration Request eForm
- Electronic Reconsideration Request E-form Instructions
- Clinical Medical Policy Review/Request Form
- Corrected (Replacement)/Voided Claim Request Form
- Electronic Payment and Remittance Advice Application – This form has been temporarily de-activated. Please email accountspayable@nhpri.org with requests or questions.
- Home Care Discharge Communication Form – New! For Home Health Providers
- Hospital Readmission Reevaluation Form
- ID Card Education Flyer (English) ID Card Education Flyer (Spanish)
- Interpreter Request eForm
- Member Education Request Form – Updated October 15, 2021
- PCP Change eForm – New! Note: Neighborhood will require exclusive use of the eForm for PCP change requests beginning April 1, 2023.
- PCP Change Form (pdf) Note: The paper/pdf PCP Change Form will not be accepted after April 1, 2023.
- Provider Claim Dispute & Provider-Initiated Appeal Form
- Provider Claim Dispute & Provider-Initiated Appeal – eForm
- Prior Authorization Request Forms
New eForm for Requesting PCP Changes | Efficient, effective, easy!
Neighborhood is happy to announce an improvement in our PCP change process. Available immediately, providers can submit for PCP changes using the newly created PCP Change eForm (electronic form).
The new PCP Change eForm is a “smart form” so a user only needs to enter minimal information and the rest of the data will automatically populate in the eForm. After submitting the PCP Change eForm, providers will receive an email confirming their submission and can verify the request was completed in NaviNet after one business day.