Forms & Documents

Provider Forms

• Provider Appeal Form - Electronic Submission
• Provider Appeal Form - Fillable PDF
• Provider Claim Dispute Form - Electronic Submission
  • Provider Payment Dispute: Providers disputing the way a claim was paid.
  • Par Provider Reconsideration: A contracted provider may file when a claim or claim line is denied. This is not a CMS requirement, but a service provided by ATRIO to contracted providers.
• Provider Claim Dispute Form - Downloadable PDF (Print and Fax)
• Medical Record Audit Response Form - Electronic Submission
• To submit claims directly to American Specialty Health please use this link
• PCP Attestation Form
• Waiver of Liability Form
• Protected Health Information Disclosure Form
• Appointment of Representative Form (CMS - 1696) (For Medicare Appeals, Grievances, and Coverage Requests only)