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Health Care Provider Forms

• Attending dentist's statement  [File: 80 KB] - Complete and mail to assure timely payment of submitted claims. (Updated 3/30/06)
• BCBSOK Authorization to Disclose Protected Health Information (Instructions)  [File: 52 KB] - This form provides a sample for the standard authorization form below.
• BCBSOK Authorization to Disclose Protected Health Information  [File: 33 KB] - This form 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. - [Updated 10/01/07]
• BlueLincs Authorization to Disclose Protected Health Information  [File: 61 KB] - This form authorizes BlueLincs HMO 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. - [Updated 9/20/05]
• BlueLincs HMO Allergy Authorization Request  [File: 78 KB] - [Added 04/27/09]
• BlueLincs HMO Referral / Authorization Request  [File: 105 KB] - Information that BlueLincs needs for referrals and authorizations. - [Updated 9/26/08]
• Claim Appeal/Reconsideration Review Request  [File: 60 KB] - [Updated 02/02/09]
• CMS-1500 User Guide  [File: 98 KB] - [Updated May 2008] This guide will help providers complete the CMS-1500 (08/05) form for patients with Blue Cross and Shield of Oklahoma insurance. 
• COB Questionnaire Form  [File: 34.4 KB] - [Updated 03/08]
• CPT-4 Modifier Use in Claims Processing  [File: 81 KB] - Information about using modifiers when submitting claims to Blue Cross and Blue Shield of Oklahoma. - [Updated 9/20/05]
• BCBSOK Significant Edits as of Jan. 9, 2009  [File: 39 KB] - [Updated 01/09/09]
• BCBSOK Significant Edits as of Nov. 3, 2009  [File: 128 KB] - [Updated 11/03/09] New!
• Immunoglobulin Therapy Request Form  [File: 27.5 KB] - [Updated 06/30/08]
• PAVET^TM Evaluation for Microprocessor Knee  [File: 104 KB] - [Updated 12/28/07]
• Predetermination Request Form  [File: 69 KB] - [Added 04/27/09]
• Provider Notification Form  [File: 94 KB]
• Synagis Statement of Medical Necessity  [File: 195 KB] - [Updated 09/18/09] - This form is for the predetermination/authorization of the medication Synagis used in the prevention of respiratory syncytial virus (RSV).
• Triessent Fax Form  [File: 168 KB]
• UB-04 User Guide  [File: 223 KB] - [Updated 9/11/08] - This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.
• Wheelchair Medical Necessity and Home Evaluation Verification  [File: 26 KB]