Click on the applicable form, complete online, print, and then mail or fax it to us.
- 835 Health Care Electronic Remittance Advice Request Form
- Accredo Prescription Enrollment Form
- Adult Problem List
- Ancillary Request to Participate Form
- Billing Authorization for Professional Associations
- Care Management Referral Form
- Claim Overpayment Refund Form
- Clinical Care Referral Form
- Continuity of Care Form
- Contraceptive Tier Exception Form
- Contraceptive Tier Exception Request Instructions
- Contract Request Form
- Coverage Protocol Exemption Form
- Coverage Protocol Exemption Instructions
- CoverMyMeds
- CVS Caremark Hemophilia Enrollment Form
- CVS Caremark Specialty Pharmacy Enrollment Form
- Electronic Funds Transfer Registration Form
- Facility Care Management Referral Form
- Fee Schedule Request Form
- Healthy Addition Prenatal Program High-Risk Member Log
- Hospital, Ancillary Facility and Supplier Business Application
- Independent Dispute Resolution 30-Day Negotiation Request Form
- Medicare Advantage Waiver of Liability Form for Non-Contracted Providers
- Medicare Clinical Care Programs Referral Form
- Member Discharge from PCP Practice (HMO and BlueMedicare HMO only)
- National Provider Identifier (NPI) Notification Form
- Non-Par Medicare Advantage Appeal form
- Notice of Medicare Non Coverage Form
- Notice of Medicare Non Coverage Form Instructions
- Panel Status Change Request Form
- Pediatric/Adolescent Problem List
- Physician and Group Request to Participate Form
- Preservice Fax Cover Sheet for Medical Records
- Provider Clinical Appeal Form
- Provider Reconsideration/Administrative Appeal Form
- Provider Information Update Form
- Provider Registration Form
- Skilled Nursing Facility Select Medication Program Order Form
Members can access a variety of member-related forms on our member self-service website including:
FB PRV FRM 001 NF 042022