Member Forms

  • Accident and Injury Form

  • Coordination of Benefits

  • Authorization for Release

  • Application for Disabled Dependent

  • Provider Request for Prescription Form

  • Request for Certificate of Credible Coverage



    To download these forms, you will need Adobe Acrobat Reader (for PDF files). If you do not have Adobe software, please visit the following website to download a free version of Adobe Acrobat Reader: http://www.adobe.com/products/acrobat/readstep2.html

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    Medical necessity review criteria used by the Medical Management department of WellSpan Population Health Services/South Central Preferred are available by calling the Medical Management department, 717-851-6801 or 800-888-1929. The criteria will be sent to you by mail, fax or e mail.