The following forms and materials are being provided to assist you in the management of your Premier Access book of business.
And don’t forget…specific patient information is available through the interactive portion of this website. All you need to access your currently enrolled patients’ data is to register on the home page of this website.
Premier Access Providers
General
- Associate Application
- Practice & Facility Information
- Form W-9: Request for TIN and Certification
- Provider_Dispute_Resolution
- Claim Form
- Emdeon ePayment Enrollment and Authorization Form
- AZ Appeals packet
Specialty Care Services Referral Form
Provider Manual / Dentist Handbook / Reference Guide
- California Government Provider Manual
- Commercial PPO Dentist Handbook
- Salzmann Index Evaluation
- Utah Government Programs Provider Manual
- Utah Medicaid Quick Reference – Primary Care Offices
- UT Medicaid Provider Incentive FAQ
Member Grievance Forms
Access Dental Providers
General
- Associate Application
- Practice & Facility Information
- Form W-9: Request for TIN and Certification
- Provider Dispute Resolution Mechanism
- Specialist Referral Form
- Claim/Encounter Form
- Transfer Request Form
- Emdeon ePayment Enrollment and Authorization Form
- California Government and Commercial Provider Manual
- GMC Notice: Added Adult Benefits as of 5/1/2014
- LAPHP Notice: Added Adult Benefits as of 5/1/2014
- Nevada DHMO Provider Manual
Member Grievance Forms
Note: In order to view these forms, Adobe Acrobat Reader must be installed on your computer. To download Acrobat Reader, click on the adjacent “Get Acrobat Reader” button. 
