Skip to main content

Forms

New Electronic Provider Forms

In order to streamline our provider information management system and comply with the No Surprises Act (NSA) effective January 1, 2022, new provider change forms are now available. Please use these forms to ensure faster processing time.

  • APP Enumeration Form
  • This form should be used to enumerate Advance Practice Providers (APPs) in Highmark's reimbursement systems.
  • Provider Directory Update Form
  • (previously the Provider Demographic Change Form)
  • Providers should utilize this electronic form to update name, address, phone number, email or web address, and specialty type for a practitioner or group OR to terminate a practitioner from a group. 
  • Supervision Data Form
  • Attestation form for Physician Assistant/CRNA/Registered Nurse First Assist (RNFA) that have a collaborating agreement with a Supervising Physician. This form must be updated as a condition of practice.
  • Tax ID Change Form
  • This form should be used only to change your Tax ID. Please continue to bill claims as previously submitted until you receive confirmation that this form has been processed.

Feedback Form

Patient Care Forms

  • pdf icon Blue Card COB Questionaire This questionnaire should be used when you see a BlueCard member from another plan and they advise you that they have duplicate insurance coverage.
  • pdf icon Blood Pressure Monitor Information covering self-measured blood pressure monitoring.

Reimbursement Forms