Medicare and HIPAA Forms

administrative Forms

A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.

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Coordination of benefits / Direct claim form.

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Express Scripts order form.

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Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.

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For use when appealing the denial of a service or claim. Appeal requests must be made within 60 calendar days of the denial notification.

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If BlueCross BlueShield of Western New York denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

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Medical benefits subscriber claim form.

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HIPAA AUTHORIZATION FORMS

Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.

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Authorization for Release of HIV Information Completion of this form will ONLY allow the release of HIV/AIDS information.

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Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health Completion of this form will ONLY allow the release of Mental Health, Alcohol or Substance Abuse information.

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You can appoint a representative – like a family member, friend, advocate, attorney, doctor or someone else – to act on your behalf. Send this form to the same location where you are sending (or have already sent):, (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact us at 1-800-329-2792, TTY: 711

We are open:
October 1 - February 14    8 a.m. to 8 p.m., 7 days a week
February 15 - September 30    8 a.m. to 8 p.m., Monday-Friday

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Feb. 15 - Sept. 30, 8 a.m. - 8 p.m., Mon. - Fri.

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This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of Western New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

Y0086_MRK1717 Approved
Content Last Updated December 15, 2016