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medicalreview
 
The following forms may be printed from your personal computer and sent to the Plan Office via a postal service. All forms are valid only when both the Social Security number and signature of the Participant are provided.


Please submit all completed forms for processing to:
Medical Review Department--Confidential
MPI Health Plan
P.O. 1999
Studio City, CA 91614-0999


Our forms are in PDF (Portable Document Format). To read and print the PDF forms, you need the free Adobe Acrobat Reader, which may already be installed in your system.
If installation is required, click the Adobe Icon.
    Adobe Acrobat

Patient and/or Participant Forms
Physician and/or Provider Forms

PATIENT/PARTICIPANT
Air Transportation Questionnaire - Participants/Patients use this form to provide information to the Plan's Medical Review Department regarding air transportation.
Change of Address - To ensure that you receive all Plan correspondence, notify us immediately of any change to your mailing address.
Foreign Claim Questionnaire - Please use this form to submit claims for medical care which occurred outside the United States.
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PHYSICIAN/PROVIDER
Pre-Authorization Request - While MPI does not require pre-authorization for any medical services or procedures, we recommend obtaining pre-authorization whenever possible to ensure coverage and proper claims processing.
Air Ambulance Questionnaire (Provider) - Your health care provider should use this form to submit additional information regarding air transportation.
Bone Stimulator Questionnaire - Preauthorization for a Bone Stimulator is not required, however, it is strongly recommended to help avoid any unnecessary out-of-pocket expenses. Please have your health care provider complete this form and return it to the Medical Review Department.
Continuous Passive Motion Request (CPM) - Preauthorization is not required, however, it is strongly recommended. Use of a CPM machine is a covered benefit following total knee replacement only.
Knee Brace Questionnaire - Off-the-shelf knee braces are covered by the Plan. If your physician feels it is necessary for you to have a custom knee brace, it is recommended that you obtain preauthorization to avoid any unnecessary out-of-pocket expenses. Please have your physician complete and submit this form.
Physician’s Sleep Study Questionnaire - Benefits for sleep studies are based on medical necessity. To assure the timely processing of these tests, please have the referring physician complete and return this questionnaire.
Speech Therapy Questionnaire - Preauthorization is not required, however it is strongly recommended. A maximum of 32 speech therapy treatments are covered per calendar year, under certain specific circumstances only.
Wig/Prosthesis Certification Form - Active and Retired Participants enrolled in the MPIHP/Blue Shield Plan are eligible for reimbursement under certain clinical circumstances only. Completing this Certification Form is part of the requirement for obtaining reimbursement.
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