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Health Care Provider Forms

Behavioral Health

Form Name and Description	Revision Date
Applied Behavior Analysis (ABA) Initial Treatment Request forms: ABA Clinical Service Request ABA Initial Assessment Request ABA Supervision via Telehealth	Updated 1/1/2019
Coordination of Care	Added 04/2015
Electroconvulsive Therapy (ECT) Request Form	Updated 1/1/2019
Focused Outpatient Management Program (FOMP) (Clinical Update Request)	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
Transition of Care Request	Added 12/30/2010

Claims

Form Name and Description	Revision Date
Claim Review Form OK Contracted Provider Claim review Form
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 01/31/2012
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
Paper forms are below, or save time and enroll online – learn more!	Added 11/06/2017
Electronic Funds Transfer Agreement
Electronic Remittance Advice Enrollment	Updated 01/12/2012

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

Form Name and Description	Revision Date
Behavioral Health Professional Areas of Expertise Form	Added 04/2015
Call Coverage Designation and Credentialing Contact Information Form	Added 04/2015
Dental Provider Nomination	Updated 07/01/2011
Fee Schedule Request Form	Updated 12/2014
Hospital Coverage Letter	Added 04/2015
NDC Fee Schedule Request Form	Updated 02/2015
Physician Assistant Prescribing Authority Supplemental Questionnaire	Added 04/2015
Physician Assistants Supervising/ Collaborating/Monitoring Physician Protocols/Duties/Scope of Practice Supplemental Questionnaire	Added 04/2015
Physician (MD/DO), Oral Surgeon (DDS/DMD) or Podiatrist (DPM) Prescribing Authority Supplemental Questionnaire	Added 04/2015
Provider Disclosure of Ownership and Control Interest Form	Added 04/2015
Provider Notification Form	Updated 07/14/2020
Solo Provider Enrollment Form Complete the Solo Provider Enrollment Form if: You are a new solo provider that is practicing under your own SSN or EIN without a Level 2-Organzational NPI For more information on how to join our networks and additional documentation requirements, please visit the Network Participation section.	Added 1/01/2020
Group/Clinic Provider Enrollment Form Complete the Group/Clinic Provider Enrollment Form if: You are a new provider being added to an existing group with a Level 2-Organization NPI You are a new group/provider with a Level 2-Organization NPI In addition to completing the Group/Clinic Provider Enrollment Form please also include the Provider Disclosure of Ownership and Control Interest Form and a Provider Roster . ^*Completion of a Group/Clinic Provider Enrollment Form is not an indicator of the type of contract that may be extended For more information on how to join our networks and additional documentation requirements, please visit the Network Participation section	Added 1/01/2020

Pharmacy

Form Name and Description	Revision Date
Specialty Pharmacy Fax Form

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