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Health Care Provider Forms
Behavioral Health
| Form Name and Description | Revision Date |
|---|---|
|
Applied Behavior Analysis (ABA) Initial Treatment Request forms: |
Updated 1/1/2019 |
Coordination of Care  |
Added 04/2015 |
| Electroconvulsive Therapy (ECT) Request Form |
Updated 1/1/2019 |
| Intensive Outpatient Program (IOP) Request Form |
Updated 3/1/2019 |
| Psychological or Neuropsychological Testing Request Form |
Updated 1/1/2019 |
| Repetitive Transcranial Magnetic Stimulation |
Updated 09/2015 |
| Transitional Care Request |
12/20/2020 |
Claims
| Form Name and Description | Revision Date |
|---|---|
| AI/AN Limited Cost-Sharing Referral Form |
05/01/2020 |
| Claim Review Form OK Contracted Provider Claim review Form |
Updated 12/14/2020 |
| Corrected Claim Form OK Corrected Provider Claim Form |
|
| Additional Information Form OK Additional Information Form |
|
| Appeal Request Form |
|
| Attending dentist's statement Complete and mail to assure timely payment of submitted claims. |
Updated 03/30/2006 |
| CMS-1500 User Guide This guide will help providers complete the CMS-1500 (08/05) form for patients with Blue Cross and Shield of Oklahoma insurance. |
Updated 07/17/2014 |
| Coordination of Benefits Questionnaire |
Updated 03/01/2008 |
| Check and Voucher Request |
|
| Medicare Reconsideration |
Updated 11/01/2011 |
| Provider Refund |
Updated 09/11/2020 |
| UB-04 User Guide This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage. |
Electronic Commerce
| Form Name and Description | Revision Date |
|---|---|
| Enroll online for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) via Availity® – learn more! | 5/3/2021 |
Medical Management
| Form Name and Description | Revision Date |
|---|---|
| BlueLincs HMO Allergy Authorization Request |
Added 04/27/2009 |
| BlueLincs HMO Referral / Authorization Request Information that BlueLincs needs for referrals and authorizations. |
Updated 07/22/2014 |
| Botulinum Toxin Form |
Added 06/18/2013 |
| Genetic Testing Form |
Added 03/04/2014 |
| Hyperbaric Oxygen Pressurization |
Added 03/26/2010 |
| Immunoglobulin Therapy Request |
Updated 06/30/2008 |
| Predetermination Request |
Updated 08/2015 |
| Synagis Statement of Medical Necessity This form is for the predetermination/authorization of the medication Synagis used in the prevention of respiratory syncytial virus (RSV). |
Updated 08/01/2012 |
| Wheelchair Medical Necessity and Home Evaluation Verification |
Member/Patient
| Form Name and Description | Revision Date |
|---|---|
| Standard Authorization Form and other HIPAA Privacy Forms Authorizes Blue Cross and Blue Shield of Oklahoma to disclose protected health information only to those individuals specified by the member. Protected health information is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. |
Network
.Pharmacy
| Form Name and Description | Revision Date |
|---|---|
| Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions | |
| Specialty Pharmacy General Use Fax Form |
|
Specialty Pharmacy Referral Forms by Therapy  |
Wellness
| Form Name and Description | Revision Date |
|---|---|
| Medicare Advantage Annual Wellness Visit Form |
Added 06/05/2020 |
Resources
| Form Name and Description | Revision Date |
|---|---|
| Asthma Action Plan Template |
Updated 01/18/2013 |
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