Forms

Forms

Download PDF forms related to:

Customer Service Forms
Dental Claim Forms
Vision Claim Forms
Health Care Provider Forms
Individual Forms
Group Forms
Prescription Drug Information

Customer Service

BCBSOK Health Benefits Claim Form [63.5KB]
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: 73 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 2/04/08)
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)
Student Verification Form [File: 55 KB] - This form is required for you to continue health and/or dental coverage for your dependent child age 19 or older, as long as he or she is an unmarried, full-time student. (Updated 7/13/09)
Dependent Student Medical Leave Form [File: 38 KB] [Added on 9/23/09]
COB Questionnaire - Blue Cross and Blue Shield of Oklahoma [File: 34.4 KB] [Updated 03/08]
COB Questionnaire - BlueLincs [File: 39 KB] - BlueLincs Coordination of Benefits Questionnaire (Updated 9/20/05)
BCBSOK Request to Access Protected Health Information [File: 24 KB] - This form allows an individual to request his or her own PHI. (Updated 10/06/08)
BCBSOK Request to Amend Protected Health Information [File: 24 KB] - This form allows an individual to request amendments to his or her own PHI. (Updated 10/06/08)
BCBSOK Confidential Communication Request Form [File: 32 KB] - Use this form to request that Blue Cross and Blue Shield of Oklahoma use an alternative location when communicating with you about your Protected Health Information. (Updated 10/06/08)
BCBSOK Request for Accounting of Protected Health Information Disclosures [File: 22 KB] - Use this form to request an accounting of how your Protected Health Information was disclosed by Blue Cross and Blue Shield of Oklahoma or its Business Associates. (Updated 10/06/08)
Response to Denied Amendment [File: 22 KB] - Use this form to file a Statement of Disagreement regarding a denied Request for Amendment or to request that your original amendment request and subsequent denial be attached to future disclosures of the Protected Health Information that you had requested to be amended. (Updated 10/06/08)
Restriction Request Form [File: 30 KB] - Use this form to request the restrictions on Blue Cross and Blue Shield of Oklahoma's use or disclosure of your Protected Health Information for payment or health care operations purposes. You may also use this form to terminate a previously granted request for restriction. (Updated 10/06/08)
HIPAA Complaint Form [File: 22 KB] - Use this form to file a HIPAA complaint (including privacy and security) with Blue Cross and Blue Shield of Oklahoma. (Updated 10/06/08)

Dental Claim Forms

Dental Claim Form (Updated 08/14/09)

Vision Claim Forms

Vision Claim Forms (Updated 3/1/2006)

Health Care Provider - Forms

BlueLincs HMO Allergy Authorization Request [File: 78 KB] [Added 04/27/09]
Predetermination Request Form [File: 69 KB] [Added 04/27/09]
Triessent Fax Form [File: 168 KB]
Wheelchair Medical Necessity and Home Evaluation Verification [File: 26 KB]
Provider Practice Change Form [File: 48.8 KB]
Claim Appeal/Reconsideration Review Request [File: 60 KB] [Updated 02/02/09]
Immunoglobulin Therapy Request Form [File: 27.5 KB] - [Updated 06/30/08]
COB Questionnaire Form [File: 34.4 KB] - [Updated 03/08]
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 repiratory syncytial virus (RSV).
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.
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.
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!
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 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 Referral / Authorization Request [File: 105 KB] - Information that BlueLincs needs for referrals and authorizations. (Updated 9/26/08)
PAVET^TMEvaluation for Microprocessor Knee [File: 104 KB] (Updated 12/28/07)

Dental

Attending dentist's statement [File: 80 KB] - Complete and mail to assure timely payment of submitted claims. (Updated 3/30/06)

Individual/Family coverage

Health Check

Brochure about Health Check [File: 2.04 MB], or call toll-free 1-866-303-BLUE (2583) for more information (Updated 07/18/08)
Health Check application [File: 1.9 MB] for Health Check Basic, Select (Updated 07/18/08)
Health Check change in membership form with no health statement [File: 113 KB] (Updated 07/18/08)

Dental (BlueSelect)

BlueSelect Dental application [118 KB] (Updated 3/30/05)

Request For Underwriting Opinion

Request For Underwriting Opinion Form [File: 37 KB]

Group (employer) coverage

NEW: Benefit Program Application (for groups with effective dates of Jan. 1, 2010 and after)

2-150 BPA Online Version [File: 293 KB ] (Updated 11/02/09)

2-150 BPA Manual Version [File: 253 KB] (Updated 11/02/09)

151+ BPA [File: 330 KB] (Updated 11/02/09)

Group Admin Document [File: 249 KB] (Updated 10/26/09)

Group Submission Checklist 2-150 [File: 176 KB] (Updated 10/26/09)

Group Submission Checklist 151+ [File: 166 KB] (Updated 10/26/09)

Dental:

Group Dental Application\Request for Change in Dental Membership Form [File: 112 KB] (Updated 9/2/08)

Group rate quotes:
Please fill out all forms which apply to your group size

Groups 2-4

Small Business Application\Request for Change in Membership\Decline Form [File: 143KB] (Updated 9/17/08)
Have each employee who plans to enroll in your health plan complete this form (including the health statement portion of the application).
Please be sure to answer all questions.

Groups 2-4, 5-9