Provider Forms
To view and download helpful forms, please select from the list below:
Advance Directive Booklet (PDF)
Appeal Reconsideration Form – Participating Providers (PDF)
Clinical and Preventive Guidelines (PDF)
Facility Credentialing Application (PDF)
Non-Contracted Provider Appeal Form (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 Site Review (PDF)
Prior Authorization Request Form (PDF)
Provider Demographic Change Form (PDF)
Quick Reference Sheet and Prior Authorization Grid (PDF)
Request for Meal Delivery Form (PDF)
Waiver of Liability Statement (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 ExtraAttn: Provider Services Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027
