Forms & Downloads

GHI HMO Pharmacy Services prescription drug claim form

Benefit Extension Treatment Plan Form
Request extensions (beyond benefit plan allowances) for Physical, Occupational and Speech Therapy and Allergies treatments.

Dental Claim Form
Non-participating dentists, complete this form to indicate the services rendered, and attach the itemized bill. (All participating network dentists must submit claims forms directly to GHI for processing.) Please note: you may only access this form after logging in to MyGHI's secure server.

Dignified Decisions – End of Life Care Program Referral Form Please complete this form to request that the member under your care be admitted for hospice services.

Optical Claim Form
For non-participating providers who render routine vision services (e.g., eye exams, lenses, frames and/or contacts).

Participating Practitioner Agreements and Application.
For Metro New York, including Nassau, Rockland, Suffolk and Westchester Counties, as well as out of state applicants, please send your completed application and agreements to: GHI, PO Box 2802, New York, NY 10117-0919. For all other counties in New York State, please send your completed application and agreements to: GHI, PO Box 4332, Kingston, NY 12402
- PPO Agreement
- PPO/HMO Application
- Provisional Credentialing Attestation Form

Please note all applications must be sent along with the corresponding signed agreement for Networks you are electing to join.

Prism Chiropractic Treatment Form (PPO)
For chiropractic services that require pre-certification, fax this treatment form to 716-712-2817 or call Prism at 1-866-284-2901.

Request a Review of a Settled Claim
Log in to myGHI for Providers and review all claims, contact our Service Department and more.

Participating Practitioner Agreements and Application.
For Metro New York, including Nassau, Rockland, Suffolk and Westchester Counties, as well as out of state applicants, please send your completed application and agreements to: GHI, PO Box 2802, New York, NY 10117-0919. For all other counties in New York State, please send your completed application and agreements to: GHI, PO Box 4332, Kingston, NY 12402
- HMO Agreement
- PPO/HMO Application
- Provisional Credentialing Attestation Form

Please note all applications must be sent along with the corresponding signed agreement for Networks you are electing to join.

Prior Authorization Form (HMO)
Prior Authorization is intended to ensure that the requested service is covered by the member's benefit, that the provider of service is participating, and that the services are medically necessary. Services will also be reviewed to ensure that the most appropriate setting is being utilized and to identify those members who may benefit from our care Management programs. Required prior authorization can be obtained by faxing this Prior Authorization Form with supporting documentation to GHI HMO at 877-508-2643.

See also: Prior authorization requirements - quick reference guide.

Prism Treatment Plan Forms (HMO)
All chiropractic care* and physical and occupational therapy services require a referral from the Primary Care Physician. The PCP should fax a copy of the referral form to Prism at 716-712-2817. After the initial visit, providers must contact Prism for additional visits by submitting this treatment plan form for review and consideration. Providers are also required to report their findings and treatments to the member's PCP.
- Chiropractic Treatment Form
- Physical and Occupational Therapy Treatment Form
*except HMO Direct Access

Radiology Pre-certification (HMO)
Pre-certification by CareCore is required for the following procedures when performed on an outpatient basis in Outpatient Hospital Facilities, Free Standing Radiology Facilities, and Non-Radiology Office-Based Settings: CT, MRI, MRA, Nuclear Medicine, PET Scans and Obstetrical Ultrasounds (more than 3 during a pregnancy). To ensure that the pre-certification process fully considers patient symptoms and clinical findings, GHI HMO requires that the referring physician obtain the pre-certification from CareCore.

Referral Form Sample (HMO)
The GHI HMO Specialty Referral Process enables Primary Care Physician (PCP) to coordinate the process by which their patients receive care from specialists. Primary Care Physicians (PCPs) who identify a need for a referral will simply give a referral number to the participating specialist. The PCP does not need to submit a copy of the referral form to GHI HMO. Assigned referrals will be valid for a period of one year from the initial date of service. Click here for complete instructions.

Request a Review of a Settled Claim
Log in to myGHI for Providers and review all claims, contact our Service Department and more.