Provider Forms and References

The following forms and references can help you stay updated on changes and other issues important to your practice.

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General Forms

Provider Self-Disclosure Form - Overpayment Refund/Notification Formopen_in_new

Prior Authorization Form

New Mexico Uniform Prior Authorization Formopen_in_new

Submit a Pre-Service Appeal and or Grievance for a Medicaid Member

Medicaid Pre-Service Appeal or Grievance

UnitedHealthcare Community Plan of New Mexico is a product of UnitedHealthcare Insurance Company.