State Farm

Documents

Decision Point/Pre-Certification Plan (Dates of Loss On and After 9/1/2023)

Decision Point/Pre-Certification Plan (Dates of Loss Prior to 11/1/2011)

Decision Point/Pre-Certification Plan (Dates of Loss On and After 11/1/2011)

Decision Point/Pre-Certification Plan (Dates of Loss On and After 12/15/2013)

Decision Point/Pre-Certification Plan (Dates of Service On or After 12/1/2017)

Conditional Assignment of Benefits (Dates of Loss Prior to 11/1/2011)

Conditional Assignment of Benefits (Dates of Loss On and After 11/1/2011)

Conditional Assignment of Benefits (Dates of Loss On and After 12/15/2013)

Conditional Assignment of Benefits (Dates of Service On or After 12/1/2017)

Provider Letter (Dates of Loss On and After 12/15/2013)

For additional resource materials and information, go to https://www.statefarm.com/claims/claims-help/pip-and-mpc-forms.

Voluntary Provider Networks

MRI/CAT Scans - Carisk Imaging

Ambulatory Surgical Center Services - CHN PPO