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Health Care Provider Forms


Behavioral Health


Form Name and DescriptionRevision Date
Clinical Update Request   Updated 03/01/2012
Electroconvulsive Therapy Request  Added 03/01/2012
Intensive Outpatient Program  Updated 03/01/2012
Outpatient Treatment Request  Updated 03/01/2012
Psychological/Neuropsychological Testing Request   Updated 03/01/2012
Transition of Care Request  Added 12/30/2010


Claims


Form Name and DescriptionRevision Date
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  Updated 03/01/2008
Medicare Reconsideration   Updated 11/1/2011
OK Claim Review (Claim Appeal/Reconsideration Review Request)  Updated 11/08/2012
Provider Refund  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 Name and DescriptionRevision Date
Electronic Funds Transfer Agreement   
Electronic Remittance Advice Enrollment  Updated 1/12/2012


Medical Management


Form Name and DescriptionRevision Date
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
Botulinum Toxin Form  Added 06/18/2013
Hyperbaric Oxygen Pressurization  Added 03/26/2010
Immunoglobulin Therapy Request  Updated 06/30/2008
Medical Policy - Erythropoiesis-Stimulating Agents  Updated 8/26/2011
PAVETTM Evaluation for Microprocessor Knee  Updated 12/28/2007
Predetermination Request   Updated 3/31/2013
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 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
Dental Provider Nomination   Updated 07/01/2011
Provider Notification   Updated 04/14/2011


Pharmacy


Form Name and DescriptionRevision Date
Specialty Pharmacy Fax Form   


Resources


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