Forms
Feedback Form
- Provider Website Feedback Form
We want to ensure that your online experience meets your needs.
Practice Guidelines
Behavioral Health Forms
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Autism Spectrum Disorder
Comprehensive Evaluation Request Form
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Behavioral Health Clinical Criteria Set Request Form
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Behavioral Health Practitioner Questionnaire
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Behavioral Health Out-of-Plan Referral Review Request Form
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Mental Health Outpatient Treatment Review Form
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Outpatient Treatment Review Form
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Outpatient Applied Behavioral Analysis Treatment Report
Patient Care Forms
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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.
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Blood Pressure Monitor
Information covering self-measured blood pressure monitoring.
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Durable Medical Equipment Preauth form
This form is used to request a Prior Authorization for Durable Medical Equipment (DME)
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Health Care Proxy Form
The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.
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Home Health Care Preauthorization Form
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In-Network Referral Form
Fillable form for fax use.
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Lead Risk Assessment
In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age.
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Medicaid Managed Care Only Home Assessment PCS
This form must be completed for Medicaid patients receiving personal care services or requesting personal care services.
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NYS Medicaid Prior Authorization Form for Prescriptions
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Out of Plan Referral Review Request Form
This form is used to request an Out-of-Plan Referral also referred to as an Out-of-Network Referral, for services outside of the Servicing Network.
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Preauthorization Form: Elective Surgery
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Preauthorization Form: Outpatient Services
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Preauthorization Form: Transplant
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Preconception Checklist
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Preauthorization / Non Formulary Drug Request Form
This preauthorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services.
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Provider Office Accident Questionnaire
This form is used to assist in determining if a patient is eligible to receive Workers' Compensation, No-Fault Automobile or Personal Liability insurance benefits due to a possible accident or injury.
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Health Care Services Referral Form
To refer a patient who is a BlueCross BlueShield member to our disease management, case management or health coaching service, complete and fax this form to the number enclosed.
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Vaccine Claim Form – Part D Member
This claim form is for reimbursement of covered Part D vaccines and their administration (injection). This form is for Providers to give to members if necessary. If requested, please ask that they check their Evidence of Coverage for specific coverage information.
Practice Administration
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Disclosure of History Form
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Disclosure of Ownership and Control Form - Facility
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Disclosure of Ownership and Control Form - Practitioner
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New Provider Enrollment & Disclosure of Ownership Control
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Nurse Practitioner Agreement/Acknowledgement
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Primary Care Physician (PCP) Change Form
This is a form that providers will supply to the patient/member when they are changing their PCP.
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Provider Demographic Change Form
Please submit this form to our Corporate Provider File Department when adding additional office locations to your practice, or if your practice moves from its current location. Please fax the completed form to 716-887-8886.
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Request to Resolve Provider Negative Balance
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Supervision Data Form
Reimbursement Forms
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Provider Claim Inquiry Form
When submitting a provider inquiry for review, please submit all materials as indicated within the form.
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Post Service Claim Appeal Form
Effective January 1, 2010 providers appealing claims that have been denied by the Utilization Management Department for experimental/investigational, cosmetic, or medical necessity will be required to submit a simplified Claims Appeal Form.