Health Care Provider Forms

Note: Unless otherwise indicated, PRINT the document and submit as indicated on the form.

General

Forms	Description
Claim Review Note: Review each form to determine the appropriate form to use Additional Information Form Claim Review Form Corrected Claim Form	Fillable
Coordination of Benefits Form	Fillable - Submit form to: Blue Cross and Blue Shield of Texas P.O. Box 660044 Dallas, TX 75266-0044
Dependent Student Medical Leave Certification Form
Hemophilia Referral Fax	Interactive
Hospital Coverage Letter	Interactive
Medicare Advantage Annual Wellness Visit Guide	Interactive
Medicare Advantage Annual Wellness Visit Form	Interactive
Out-of-Network — Enrollee Notification Form for Regulated Business (Use this form if "TDI" is on member's ID card)
Out-of-Network — Enrollee Notification Form for Non-Regulated Business (Use this form if "TDI” is not on member's ID card)
PPO Notification for non pre-cert surgeries per Texas Administrative Code 3.3703	Fillable
Prior Authorization - Standard Health Care Services Prior Authorization Form	Fillable
Prior Authorization Standard Prescription Drugs	Fillable
Provider Refund	Fillable
Recommended Clinical Review Form – Outpatient Services (formerly the Predetermination of Benefits form)	Fillable
Room Rate Update Notification	Fillable
Transitional Care Request	Fillable
Verification Of Benefits Processing and Request Form	Verification of Benefit Form Interactive

Medical Policy Forms (Note: May be used as a supplement to medical record documentation)

Form Title	Description
Bariatric Surgery	Interactive
Cranial Remolding Orthosis (CRO) Device	Interactive
Genetic Testing	Instructions Fillable
Hyperbaric Oxygen (HBO) Pressurization	Interactive
Oncotype DX	Interactive
Varicose Vein Management	Interactive
Wheelchair Medical Necessity and Home Evaluation Verification	Interactive

Behavioral Health/Mental Health Forms for ERS Participants

Form Title	Description
Mental Health Forms for Employee Retirement System of Texas (ERS)	Select Link for list of forms

Behavioral Health/Mental Health Forms for TRSParticipants

Form Title	Description
Behavioral Health Forms for Teacher Retirement System of Texas (TRS)	Select Link for list of forms

Behavioral Health for Other BCBSTX Plans

(Note: for ERS or TRS participants refer to specific form links above)

Form Title

Applied Behavior Analysis (ABA) forms:

Behavioral Health Discharge Clinical Form

Coordination of Care

Electroconvulsive Therapy (ECT) Request

Intensive Outpatient Program (IOP) Request

Psychological/Neuropsychological Testing Request

Repetitive or Deep Transcranial Magnetic Stimulation (rTMS or dTMS)

Transitional Care Request

Pharmacy

Form Title	Description
Express Scripts^® Pharmacy Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions	Fax forms must be faxed from a physician's office
Accredo Specialty Pharmacy General Use Fax Form	Specialty pharmacy drugs fax form for general use
Accredo Specialty Pharmacy Referral Forms by Therapy	Specialty pharmacy drugs fax form by drug therapy
Prior Authorization Standard Prescription Drugs	Fillable
Quantity Limit Override Request	Request to override the dispensing/quantity limit
Topical Verapamil Override Request Specialty pharmacy drugs fax form for general use