Document Submission Cover Sheets

Select the appropriate cover sheet title below each time you need to send back-up documentation to a claim, prior authorization request, pharmacy claim/adjustment form or rate request, or for Provider Enrollment information updates.

NOTE: You must use Adobe Acrobat to open and use the coversheets below. If you use a program other than Adobe Acrobat, the coversheet will not be produced correctly and may delay the processing of your claim or authorization request. If you don't have Adobe for reading Portable Document Format (PDF) files, or are having problems opening our PDF files, click here.

Send cover sheets and back-up documentation to:

Division of Eligibility and Service Delivery
RE: Cover Sheets and Back-up Documentation
PO Box 45535
Olympia, WA 98504-5535
1-866-668-1214 (fax)

NOTE: You may include additional justifying information when you submit the initial request. Use either the:

  • General Information for Authorization form DSHS 13-835; or
  • Pharmacy Information for Authorization form DSHS 13-835a

to submit supporting documentation after the initial request has been sent, and you have received a reference/authorization number, please use the barcode cover sheets:

  • PA Pend Form; or
  • Pharmacy PA Supporting Documents (pharmacy).

The properly completed barcode coversheet will allow your supporting documentation to automatically index into the ProviderOne system.

  1. Provider Information Update Requests
  2. Provider EFT (Electronic Funds Transfer) Form
  3. ADA 2006 Dental Attachments (when supporting documents are detached from original claim)
  4. UB-04 Attachments (when supporting documents are detached from original claim)
  5. CMS-1500 Attachments (when supporting documents are detached from original claim)
  6. ECB (Electronic Claim Backup) Attachments
  7. PA (Prior Authorization) Pend Forms (when supporting documents are submitted to support a PA request)
  8. Pharmacy Claim Adjust Form
  9. Pharmacy Claim Forms
  10. Pharmacy Claims Attachments
  11. CPA (Core Provider Agreement) DSHS 08-048
  12. Pharmacy PA Supporting Docs
  13. Provider Enrollment Supporting Documents