Forms

PDFs of our most commonly used forms are available below:

• AIM Preauthorization/RQI Request Fax Form
• Continuation of Care Form
• Emergency Room Review Form
• 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
• Peer to Peer Request Form
• Physician Certificate of Attestation Form
• Provider Claim Inquiry Form
• Provider Change Form
• Request to Update Procedure Code(s) on an Existing Authorization Form
• Surgical Team (Modifier-66) Documentation Form

If you are interested in having a registered nurse Health Coach work with your Independence Blue Cross patients, please complete a physician referral form or contact us by calling 1-800-ASK-BLUE (1-800-275-2583).

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

Please note that 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.

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.

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