Forms

PDFs of our most commonly used forms are available below:

• AIM Preauthorization/RQI Request Fax Form
• Case Management Referral Form
• Connections Physician's Referral Form — for eligible members
• Continuation of Care Form
• Emergency Room Review Form
• FutureScripts^® Direct Ship Specialty Pharmacy Program
• FutureScripts Direct Ship Specialty Pharmacy Vaccine Program
• HIPAA Authorization Form — authorizes Independence Blue Cross to release member's health information
• HIPAA Personal Representative Form — appoints another person as member's personal representative
• Implant Reimbursement Request Form
• Member Consent for Financial Responsibility Form
• Non-Formulary Exception Request Form
• Overpayment Refund Form
• PCP to Behavioral Health Provider Communication Form
• Physician Certificate of Attestation Form
• Provider Claim Inquiry Form
• Provider Change Form
• Surgical Team (Modifier-66) Documentation Form

Providers must complete a request form for all medications requiring prior authorization. More information about this process is available on the prior authorization page.

Request Other Forms

You may obtain other forms, including the Baby BluePrints^® Initial Maternity Patient Questionnaire, by completing the online Provider Supply Line Order Form or by calling the Provider Supply Line at 1-800-858-4728.

Forms are not used to verify member eligibility or to check the status of a claim. Instead, please use the NaviNet^® web portal or call 1-800-ASK-BLUE (1-800-275-2583) to access the Provider Automated System.

For all other questions and inquiries, call Customer Service at 1-800-ASK-BLUE.

Claim forms

Claim forms, such as the CMS-1500, are not available through the Provider Supply Line; they are available for purchase at many local office supply stores.

NaviNet^® is a registered trademark of NaviNet, Inc., an independent company.