Health Care Provider Forms
Behavioral Health
Form Name and Description | Revision Date |
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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 |
Focused Outpatient Management Program 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 |
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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 |
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Additional Information Form ![]() OK Additional Information Form |
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Appeal Request Form ![]() |
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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 ![]() |
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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 |
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Paper forms are below, or save time and enroll online – learn more! | Added 11/06/2017 |
Electronic Funds Transfer Agreement ![]() |
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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 |
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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 |
---|---|
ADA Survey & Attest ![]() |
Added 03/2021 |
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 09/30/2020 |
Solo Provider Onboarding Form ![]() Complete the Solo Provider Onboarding Form if:
For more information on how to join our networks and additional documentation requirements, please visit the Network Participation section.
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Updated 10/01/20 |
Group/Clinic Provider Onboarding Form ![]() Complete the Group/Clinic Provider Onboarding Form if:
In addition to completing the Group/Clinic Provider Onboarding Form please also include the Provider Disclosure of Ownership and Control Interest Form *Completion of a Group/Clinic Provider Onboarding 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 |
Updated 10/01/20 |
Pharmacy
Form Name and Description | Revision Date |
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Specialty Pharmacy Fax Form ![]() |
Wellness
Form Name and Description | Revision Date |
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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 |