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
