Health Care Provider Forms

Behavioral Health

Form Name and Description	Revision Date
Applied Behavior Analysis (ABA) Initial Treatment Request forms: ABA Clinical Service Request ABA Initial Assessment Request ABA Supervision via Telehealth ABA BCBA Change Form	Updated 01/25/2024
Behavioral Health Discharge Clinic Form	Added 10/2022
Behavioral Health Post Service Review Request Form (Commercial Members Only)	Added 8/30/2024
Coordination of Care	Updated 04/08/2024
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
Request for Continued Access to Providers	Updated 11/21/2024

Claims

Form Name and Description	Revision Date
AI/AN Limited Cost-Sharing Referral Form	08/29/2024
Claim Review Form OK Contracted Provider Claim review Form	Updated 12/21/2023
Corrected Claim Form OK Corrected Provider Claim Form	Updated 11/21/2023
Additional Information Form OK Additional Information Form	Updated 11/21/2023
Expedited Pre-service Clinical Appeal Request Form (Commercial networks only)	03/07/2022
Dental Claim Form Complete and mail to assure timely payment of submitted claims.	Updated 12/2023
CMS-1500 User Guide This guide will help providers complete the CMS-1500 (Version 02/12) form for patients with Blue Cross and Shield of Oklahoma insurance.	Updated 12/20/2023
Coordination of Benefits Questionnaire	Updated 03/01/2008
Check and Voucher Request	Updated 02/12/2024
Provider Refund	Updated 09/2024

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 Referral / Authorization Request Information that BlueLincs needs for referrals and authorizations.	Updated 02/26/2024
MyBlue HMO PCP Referral	Updated 03/07/2024
Recommended Clinical Review (Predetermination) Request	Updated 11/21/2023
Request for Continued Access to Providers	Updated 11/21/2024
Wheelchair Medical Necessity and Home Evaluation Verification	Updated 11/21/2023

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
Advanced Practice Nurses	Added 09/2024
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 For more information on how to join our networks and additional documentation requirements, please visit the Network Participation section.	Updated 12/20/2023
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 Affordable Care Act (ACA) Copay Waiver Form and Program Summary to request $0 member cost share for preventive drug products not covered on a BCBSOK commercial plan drug list Formulary Coverage Exception form to request coverage for drug products not covered on a BCBSOK commercial plan drug list	Added 04/08/2024 Added 04/08/2024

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

Affordable Care Act (ACA) Copay Waiver Form and Program Summary to request $0 member cost share for preventive drug products not covered on a BCBSOK commercial plan drug list

Formulary Coverage Exception form to request coverage for drug products not covered on a BCBSOK commercial plan drug list

Added 04/08/2024

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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