Need to access forms and your personal plan documents? For your privacy and protection, please login to your OhioHealthy account. Just looking for forms? The forms below are immediately available for you to download without signing in.
Forms
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OhioHealthy Dependent with Disability Application
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OhioHealthy Network Exception Request Form
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Travel and Lodging Benefit Reimbursement Predetermination and Claim Form
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Prescription Drug Claim Form
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Prior Authorization Request Form - Fully Funded
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Prior Authorization Request Form - Level Funded
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Prior Authorization Request Form - Self Funded
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Transition of Care / Continuity of Care Form
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Transition of Care / Continuity of Care Flyer
Case Management from Registered Nurses
As part of your health benefit plan, you have access to case management - a voluntary program to help you and your family deal with chronic or serious illnesses or injuries. This program is available to you at no additional out-of-pocket cost.
Forms for OhioHealthy Providers
Medical Authorizations
Drug Authorizations
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OhioHealthy Archimedes PA Form for Specialty Drugs
Behavioral Health Authorizations
Hospital Review Team
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Authorization Request for Inpatient and Observation Services
Network Documentation
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Web Site Hospital Application 2022
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Web Site Ancillary Application 2022
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W-9 Form
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OhioHealthy Collaborative Advanced Practitioner Form
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OhioHealthy Provider Nomination Form
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OhioHealthy Practitioner Agreement
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OhioHealthy Advanced Practitioner Agreement
Update your information
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OhioHealthy Provider Change Form