Forms
Professional
The following forms can be completed and submitted online.
The following documents are in PDF format.
- Certificates of Medical Necessity
- For supplies/medical equipment without specific CMN*
(Form 15-405) - Oxygen – This CMN is not required with the claim. It is completed by the ordering physician and maintained in file by the oxygen provider.*
(Form 15-406) - Seat lift chair/patient lift and sit to stand/standing frame systems*
(Form 15-503) - Hospital Bed*
(Form 15-506) - Lymphadema Compressor*
- (Form 15-508)
- Manual Wheelchair*
(Form 15-509) - Motorized Wheelchair*
(Form 15-510) - Power Operated Vehicle*
(Form 15-513) - Pulse Oximeter*
(Form 15-514) - Support Surfaces (Mattresses and Pads) *
(Form 15-515) - Claim Appeal Representative Authorization Form *
- Electronic Fund Transfer Form *
- Limited Patient Waiver *
(Form 15-169) - Medical Necessity Form for Periodontal Therapy with a Controlled Chemotherapy Agent *
(Form 15-721) - New Directions Outpatient Treatment Request Form *
(Form 42-1) - New Directions Outpatient Treatment Request Form - for Medication Management Services *
(Form 42-2) - OPL Deduct Authorization Form*
(Form 29-203) - Other Party Liabilty Questionnaire
- Predetermination Request Form *
(Form 15-17) - Prior Authorization for ACEI/ARB, SSRI and SNRI *
- Prior Authorization for COX-2 *
- Prior Authorization for OxyContin Medication *
- Prior Authorization for Synagis Medication (use this form if your practice purchases Synagis and bills BCBSKS) *
- Prior Authorization for Synagis Medication (use this form if Synagis will be ordered and shipped from Triessent pharmacy) *
- Prior Authorization for Xolair Medication *
- Provider Change of Information Form
- Provider & Organizational NPI Notification Form
- Refund/Deduct Authorization*
(Form 29-202)
* You may fill out and print this form using your acrobat reader program.
Institutional
The following forms can be completed and submitted online.
The following documents are in PDF format.
- Electronic Fund Transfer (EFT) Form *
- New Directions Inpatient/PHP/IOP Treatment Request *
(Form 42-3) - NPI Information Changes
- Notice of Personal Financial Obligation
- OPL Deduct Authorization Form*
(Form 29-203) - OPL Questionnaire
- Partial-Day Treatment Program Release Form*
- Provider File Update Form
- Refund/Deduct Authorization*
(Form 29-202)
* You may fill out and print this form using your acrobat reader program.