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Health Care Provider Forms


Behavioral Health


Form Name and DescriptionRevision Date

Applied Behavior Analysis (ABA) Initial Treatment Request forms:

Applied Behavior Analysis (ABA) Managed Care/Concurrent Review Form PDF Document

Updated 12/2016
Coordination of Care PDF Document Added 04/2015
Clinical Update Request  PDF Document Updated 09/2015
Electroconvulsive Therapy Request PDF Document Updated 09/2015
Intensive Outpatient Program PDF Document Updated 09/2015
Psychological/Neuropsychological Testing Request  PDF Document Updated 09/2015
Repetitive Transcranial Magnetic Stimulation  PDF Document Updated 09/2015
Transition of Care Request PDF Document Added 12/30/2010


Claims


Form Name and DescriptionRevision Date
Claim Review Form PDF Document
OK Contracted Provider Claim review Form
 
Corrected Claim Form PDF Document
OK Corrected Provider Claim Form
 
Additional Information Form PDF Document
OK Additional Information Form
 
Review Request Form PDF Document  
Attending dentist's statement PDF Document
Complete and mail to assure timely payment of submitted claims.
Updated 03/30/2006
CMS-1500 User Guide PDF Document
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 PDF Document Updated 03/01/2008
Check and Voucher Request PDF Document
 
Medicare Reconsideration  PDF Document Updated 11/01/2011
Provider Refund PDF Document Updated 01/31/2012
UB-04 User Guide PDF Document
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 PDF Document  
Electronic Remittance Advice Enrollment PDF Document Updated 01/12/2012


Medical Management


Form Name and DescriptionRevision Date
BlueLincs HMO Allergy Authorization Request PDF Document Added 04/27/2009
BlueLincs HMO Referral / Authorization Request PDF Document
Information that BlueLincs needs for referrals and authorizations.
Updated 07/22/2014
Botulinum Toxin Form PDF Document Added 06/18/2013
Genetic Testing Form PDF Document Added 03/04/2014
Hyperbaric Oxygen Pressurization PDF Document Added 03/26/2010
Immunoglobulin Therapy Request PDF Document Updated 06/30/2008
Medical Policy - Erythropoiesis-Stimulating Agents PDF Document Updated 08/26/2011
PAVETTM Evaluation for Microprocessor Knee PDF Document Updated 12/03/2013
Proton Beam Radiation Therapy
Physician Worksheet
 PDF Document
Updated 12/10/2014
Predetermination Request  PDF Document Updated 08/2015
Synagis Statement of Medical Necessity PDF Document
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 PDF Document  


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
Advanced Practice Nurses Collaborating/Supervising/Monitoring Physician Protocols/Duties/Scope of Practice Supplemental Questionnaire PDF Document Added 04/2015
Advanced Practice Nurse Prescribing Authority Supplemental Questionnaire PDF Document Added 04/2015
Behavioral Health Professional Areas of Expertise Form PDF Document Added 04/2015
Call Coverage Designation and Credentialing Contact Information Form PDF Document Added 04/2015
Dental Provider Nomination PDF Document Updated 07/01/2011
Fee Schedule Request Form PDF Document Updated 12/2014
Group Provider Record/Contracting Packet Form PDF Document Added 04/2015
Hospital Coverage Letter PDF Document Added 04/2015
NDC Fee Schedule Request Form PDF Document Updated 02/2015
Physician Assistant Prescribing Authority Supplemental Questionnaire PDF Document Added 04/2015
Physician Assistants Supervising/ Collaborating/Monitoring Physician Protocols/Duties/Scope of Practice Supplemental Questionnaire PDF Document Added 04/2015
Physician (MD/DO), Oral Surgeon (DDS/DMD) or Podiatrist (DPM) Prescribing Authority Supplemental Questionnaire PDF Document Added 04/2015
Provider Disclosure of Ownership and Control Interest Form PDF Document Added 04/2015
Provider Notification Form PDF Document Updated 10/2015
Professional Provider Record/Contracting Packet PDF Document Added 04/2015


Pharmacy


Form Name and DescriptionRevision Date
Specialty Pharmacy Fax Form PDF Document  


Resources


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