Forms and Materials for Our Providers

Click on a specific form below to download and print a current version.

Administrative Forms

Credentialing Application
Locum Tenens Application
Organizational Credentialing Application

Credentialing Application
Locum Tenens Application
Organizational Credentialing Application

Credentialing Application 2012
Credentialing Attachment A 2012
Locum Tenens Application
Organizational Credentialing Application
Recredentialing Application 2012
Recredentialing Attachment A 2012

Credentialing Application
Locum Tenens Application
Organizational Credentialing Application

Benefit Enrollment & Maintenance Transaction Companion Guide (834)
Colonoscopy Benefit Clarification
Dental Transaction Companion Guide (837)
Diagnostic Imaging Management FAQ
Diagnostic Imaging Preauthorization List
Electronic Claims Transmission
Healthcare Claim Payment-Advice Transaction Companion Guide (835)
Institutional Transaction Companion Guide (837)
Mental Health and Chemical Dependency Parity FAQ
Mental Health and Chemical Dependency Parity Table
National Provider Identifier FAQ
New and Emerging Technologies: Coverage Status
PacificSource.com and InTouch for Providers
Prenatal Program
Professional Transaction Companion Guide (837)
Specialty Pharmacy Services
Tobacco Cessation Flier
Weight Management
Who To Contact

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Registration Information

Please contact Idaho Physicians Network (IPN) or the BrightPath Network for credentialing information.

Phone: 208.333.1513 or 866.476-1076
E-mail: ipn@ipnmd.com

Complete the online BrightPath Provider Nomination form, or call 208.381.1564

Last updated 3/25/2010

Accident Report
Chemical Dependency Outpatient Treatment Plan (commercial plans only)
Claim Form - CMS 1500
Claim Form - Dental
Claim Form - UB04
Code Book Order Form 2014
Community Health Excellence (CHE) Application
Community Health Excellence (CHE) Budget Form
Contested Refund Form
Corrected Claim Form
Corrected Dental Claim Form
CPAP-BiPap Rent to Purchase Request
Designation of Authorized Representative
Disabled Dependent Certification
Electronic Remittance Advice and EFT Enrollment Form (835)
Mental Health Outpatient Treatment Plan (commercial plans only)
Preauthorization Request - Idaho and Montana (Medical)
Preauthorization Request - Oregon (Medical)
Preauthorization Request (Behavioral Health, commercial plans only)
Preauthorization Request (Dental)
Prescription Drug Preauthorization Request (Fax)
Referral Authorization Request
W-9