Provider Forms

To view and download helpful forms, please select from the list below:

Advance Directive Booklet (PDF)

Claim Dispute Resolution Request Form (PDF)

Clinical and Preventive Guidelines (PDF)

Contracted Provider Reconsideration (Appeal) Form (PDF)

Non-Contracted Provider Appeal Form (PDF)

Practitioner Site Review (PDF)

Prior Authorization Request Form (PDF)

Provider Demographic Change Form (PDF)

Pharmacy Coverage Determination Form (PDF)

Quick Reference Grid and Prior Authorization Grid (PDF)

Request for Meal Delivery Form (PDF)

Waiver of Liability Statement (PDF)


NOTE: The following credentialing applications are provided for your convenience to begin the credentialing process to participate with Windsor Health Plan. It takes a completed application AND an executed contract before your application can be submitted to the Credentialing Committee for approval. If you are not contracted and would like a Contracting Representative to contact you, please call (866) 270-5223.

Facility Credentialing Application (PDF)

Behavioral Organizational Facility Credentialing Application (PDF)

Practitioner Credentialing Application (PDF)

Practitioner Credentialing Application
Arkansas – MD and DO only (PDF)

Practitioner Credentialing Application
Mississippi – MD and DO only:

           MS Application Check List (PDF)

           MS State Credentialing Application (PDF)


Practitioner Credentialing Application
South Carolina – Check List (PDF)

Practitioner Recredentialing Application (for all providers except AR & MS MD/DO providers) (PDF)


Of course, if you need additional assistance with administrative or operational issues, you can always contact our Provider Services Department at 615-782-7878 or by e-mail at providers@windsorextra.com.

You can also reach us by U.S. Mail:

Windsor Medicare Extra
Attn: Provider Services Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027