Our most frequently requested forms for providers are available below in Adobe Acrobat PDF format. You will need Adobe Acrobat Reader to view the forms; this can be downloaded free of charge from Adobe's site.
Just click on the appropriate form, print the form, fill it out, and mail it in.
- A Guide for Completing the CMS-1500 Form
- Application for Facility/Agency/Vendor Participation
- Application for Provider Participation
- Blue Medicare Private Fee-For-Service (PFFS) Terms and Conditions
- Coordination of Benefits Questionnaire
- Fax Referral Form
- National Provider Identifier Submission Form
- Outpatient Treatment Report
- PAVET Evaluation for Microprocessor Knee
- Provider Refund Form
- Provider Request for Appeal on Behalf of a Member
- Provider Request for Claim Review
- Request for Taxpayer Identification Number and Certification (W-9 Form)
- Request to Establish or Revise a Facility Record
- Request to Establish or Revise a Provider Record
- Rx Drug PrimeMail Fax Form (must be faxed from a physician's office)
- Rx Drug Prior Authorization Form
- Standard Authorization Form to Use or Disclose Protected Health Information
- Transitional Care Questionnaire
- UB04 User Guide
