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Health Care Provider Forms
Behavioral Health
| Form | Description |
|---|---|
Clinical Update Request Form  |
[Added 12/15/2011] |
| Intensive Outpatient Program (IOP) Form |
[Added 12/15/2011] |
| Outpatient Treatment Request (OTR) Form |
[Added 12/30/2010] |
| Psychological/Neuropsychological Testing Request Form |
[Added 12/30/2010] |
| Transition of Care Request Form |
[Added 12/30/2010] |
Claims
| Form | Description |
|---|---|
| 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. |
| Coordination of Benefits Questionnaire Form |
[Updated 03/2008] |
| Medicare Reconsideration Form |
[Updated 11/1/2011] |
| OK Claim Review Form (Claim Appeal/Reconsideration Review Request Form) |
[Added 08/02/2011] |
| Provider Refund Form |
[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 | Description |
|---|---|
| Electronic Funds Transfer (EFT) Agreement |
|
| Electronic Remittance Advice (ERA) Enrollment Form |
[Updated 1/12/2012] |
Medical Management
| Form | Description |
|---|---|
| BlueLincs HMO Allergy Authorization Request |
[Added 04/27/2009] |
| BlueLincs HMO Referral / Authorization Request |
Information that BlueLincs needs for referrals and authorizations. — [Updated 09/26/2008] |
| Hyperbaric Oxygen (HBO) Pressurization Form |
[Added on 03/26/2010] |
| Immunoglobulin Therapy Request Form [File: 27.5 KB] |
[Updated 06/30/2008] |
| Medical Policy - Erythropoiesis-Stimulating Agents (ESAs) |
[Updated 8/26/2011] |
| PAVETTM Evaluation for Microprocessor Knee [File: 104 KB] |
[Updated 12/28/2007] |
| Predetermination Request Form [File: 69 KB] |
[Updated 11/1/2011] |
| Synagis Statement of Medical Necessity [File: 195 KB] |
This form is for the predetermination/authorization of the medication Synagis used in the prevention of respiratory syncytial virus (RSV). — [Updated 09/07/2010] |
| Wheelchair Medical Necessity and Home Evaluation Verification [File: 26 KB] |
Member/Patient
| Form | Description |
|---|---|
| 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 08/04/2011] |
| 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 09/20/2005] |
Network
| Form | Description |
|---|---|
| Dental Nomination Form [File: 78 KB] |
Updated 07/01/2011 |
| Provider Notification Form [File: 149 KB] |
Updated 04/14/2011 |
Pharmacy
| Form | Description |
|---|---|
| Triessent Fax Form [File: 168 KB] |
