Health Care Provider Forms


Behavioral Health

Form Name and Description Revision Date

Applied Behavior Analysis (ABA) Initial Treatment Request forms:

 Updated 1/1/2019
Behavioral Health Discharge Clinic Form Added 10/2022
Coordination of Care Added 04/2015
Electroconvulsive Therapy (ECT) Request Form  Updated 8/14/2023
Intensive Outpatient Program (IOP) Request Form  Updated 8/14/2023
Psychological or Neuropsychological Testing Request Form  Updated 3/16/2023
Repetitive Transcranial Magnetic Stimulation  Updated 09/2015
Therapeutic Behavioral On-Site Services Request Form  Updated 04/14/2023
Transitional Care Request 12/20/2020

 

Claims

Form Name and Description Revision Date
AI/AN Limited Cost-Sharing Referral Form 05/01/2020
Claim Review Form 
OK Contracted Provider Claim review Form		 Updated 02/06/2023
Corrected Claim Form 
OK Corrected Provider Claim Form		  
Additional Information Form 
OK Additional Information Form		  
Appeal Request Form    
Expedited Pre-service Clinical Appeal Request Form (Commercial networks only) 03/07/2022
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.		 Updated 07/17/2014
Coordination of Benefits Questionnaire Updated 03/01/2008
Check and Voucher Request 
  
Provider Refund Updated 09/11/2020
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 Description Revision 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 Description Revision Date
BlueLincs HMO Allergy Authorization Request Added 04/27/2009
BlueLincs HMO Referral / Authorization Request 
Information that BlueLincs needs for referrals and authorizations.		 Updated 07/22/2014
Botulinum Toxin Form Added 06/18/2013
Genetic Testing Form Added 03/04/2014
Hyperbaric Oxygen Pressurization Added 03/26/2010
Immunoglobulin Therapy Request Updated 06/30/2008
Recommended Clinical Review (Predetermination) Request Updated 06/21/2023
Wheelchair Medical Necessity and Home Evaluation Verification

 

Member/Patient

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

Provider Roster Excel Document

For more information on how to join our networks and additional documentation requirements, please visit the Network Participation section.

 Updated 10/11/2022
Room Rate Registration Form 11/04/2021

Pharmacy

Form Name and Description Revision Date

Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or

call 888-327-9791 for faxing instructions.

Specialty Pharmacy Fax Form

Specialty Pharmacy Referral Forms by Therapy

  

 

Wellness

Form Name and Description Revision Date
Medicare Advantage Annual Wellness Visit Form Added 06/05/2020

 

Resources

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

 

 

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