The forms below are available as PDF files. If you do not have Adobe® Reader®, download it free of charge at Adobe's site.
Claims
- CMS-1500 User Guide

- Coordination of Benefits Questionnaire

- Provider Refund Form

- Provider Request for Appeal on Behalf of a Member

- Provider Request for Claim Review

- UB04 User Guide

Electronic Commerce
Medical Management
- BlueSalud Notice of Birth
– Form and Instructions - BlueSalud Referral and Transition of Care Request

- Catastrophic Petition Request

- Hyperbaric Oxygen (HBO) Pressurization Request Form

- Immunoglobulin Therapy Request Form

- Outpatient Treatment Report

- PAVET Evaluation for Microprocessor Knee

- Preauthorization Request

- Synagis Prior Authorization Form

- Transitional Care Request

- Wheelchair Medical Necessity and Home Evaluation Verification

Member
- Dependent Student Medical Leave Certification Form

- Standard Authorization Form to Use or Disclose Protected Health Information

Network
- Application for Facility/Agency/Vendor Participation

- Application for Legal Status Change

- Fee Schedule Request

- Request for Taxpayer Identification Number and Certification
(W-9 Form) - Request to Establish or Revise a Non-Contracted Facility Record

Pharmacy
- Rx Drug PrimeMail Fax Form
(must be faxed from a physician's office) - Rx Drug Prior Authorization Form

- Specialty Pharmacy - Triessent Fax Form



