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Health Care Provider Forms


Behavioral Health


Form Name and DescriptionRevision Date

Applied Behavior Analysis (ABA) Initial Treatment Request forms:

 Updated 1/1/2019
Coordination of Care PDF Document Added 04/2015
Electroconvulsive Therapy (ECT) Request Form  PDF Document Updated 1/1/2019
Intensive Outpatient Program (IOP) Request Form  PDF Document Updated 3/1/2019
Psychological or Neuropsychological Testing Request Form  PDF Document Updated 1/1/2019
Repetitive Transcranial Magnetic Stimulation  PDF Document Updated 09/2015
Transitional Care Request PDF Document 12/20/2020


Claims


Form Name and DescriptionRevision Date
AI/AN Limited Cost-Sharing Referral Form PDF Document 05/01/2020
Claim Review Form PDF Document
OK Contracted Provider Claim review Form		 Updated 12/14/2020
Corrected Claim Form PDF Document
OK Corrected Provider Claim Form		  
Additional Information Form PDF Document
OK Additional Information Form		  
Appeal Request Form PDF Document  
Attending dentist's statement PDF Document
Complete and mail to assure timely payment of submitted claims.		 Updated 03/30/2006
CMS-1500 User Guide PDF Document
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 PDF Document Updated 03/01/2008
Check and Voucher Request PDF Document
  
Medicare Reconsideration  PDF Document Updated 11/01/2011
Provider Refund PDF Document Updated 09/11/2020
UB-04 User Guide PDF Document
This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.		  


Electronic Commerce


Form Name and DescriptionRevision 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 DescriptionRevision Date
BlueLincs HMO Allergy Authorization Request PDF Document Added 04/27/2009
BlueLincs HMO Referral / Authorization Request PDF Document
Information that BlueLincs needs for referrals and authorizations.		 Updated 07/22/2014
Botulinum Toxin Form PDF Document Added 06/18/2013
Genetic Testing Form PDF Document Added 03/04/2014
Hyperbaric Oxygen Pressurization PDF Document Added 03/26/2010
Immunoglobulin Therapy Request PDF Document Updated 06/30/2008
Predetermination Request  PDF Document Updated 08/2015
Synagis Statement of Medical Necessity PDF Document
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 PDF Document  


Member/Patient


Form Name and DescriptionRevision 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 DescriptionRevision Date
ADA Survey & Attest PDF Document Added 03/2021
Behavioral Health Professional Areas of Expertise Form PDF Document Added 04/2015
Call Coverage Designation and Credentialing Contact Information Form PDF Document Added 04/2015
Dental Provider Nomination PDF Document Updated 07/01/2011
Fee Schedule Request Form PDF Document Updated 12/2014
Hospital Coverage Letter PDF Document Added 04/2015
NDC Fee Schedule Request Form PDF Document Updated 02/2015
Physician Assistant Prescribing Authority Supplemental Questionnaire PDF Document Added 04/2015
Physician Assistants Supervising/ Collaborating/Monitoring Physician Protocols/Duties/Scope of Practice Supplemental Questionnaire PDF Document Added 04/2015
Physician (MD/DO), Oral Surgeon (DDS/DMD) or Podiatrist (DPM) Prescribing Authority Supplemental Questionnaire PDF Document Added 04/2015
Provider Disclosure of Ownership and Control Interest Form PDF Document Added 04/2015
Provider Notification Form PDF Document Updated 09/30/2020
Solo Provider Onboarding Form  PDF Document

Complete the Solo Provider Onboarding 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.

 

 

 Updated 10/01/20
Group/Clinic Provider Onboarding Form PDF Document

Complete the Group/Clinic Provider Onboarding 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 Onboarding Form please also include the Provider Disclosure of Ownership and Control Interest Form PDF Document and a Provider Roster Excel Document.

*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 DescriptionRevision Date
Specialty Pharmacy Fax Form PDF Document  


Wellness


Form Name and DescriptionRevision Date
Medicare Advantage Annual Wellness Visit Form PDF Document Added 06/05/2020


Resources


Form Name and DescriptionRevision Date
Asthma Action Plan Template PDF Document Updated 01/18/2013

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