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PDFs of our most commonly used forms are available below:
- Continuation of Care Request Form
- Emergency Room Review Form
- FutureScripts® Non-Formulary Exception Request Form
- HIPAA Authorization to Release Information Form — authorizes Independence Blue Cross to release member’s health information
- HIPAA Personal Representative Request Form — appoints another person as member’s personal representative
- Implant Reimbursement Request Form
- Member Consent for Financial Responsibility for Unreferred/Non-covered Services Form
- Overpayment/Refund Form
- PCP to Behavioral Health Provider Communication Form
- Peer to Peer Request Fax 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
The forms listed below are only for drugs covered under the medical benefit. Injectable drugs listed in bold indicate preferred brands. Choosing one of these preferred brands does not affect the member’s cost-sharing for the drug.
- Direct Ship Injectables Request Form (general form for agents not listed below)
- Erythropoiesis-Stimulating Agents
- Botulinum toxins (Botox®, Dysport®, Myobloc®)
- Makena™ (17 alpha-hydroxyprogesterone caproate)
- Psoriasis agents (Stelara®)
- Synagis® (palivizumab)
- Viscosupplementation (hyaluronate acid products) (Orthovisc®, Synvisc®, Synvisc–One®, Euflexxa®, Gel-One ®, Supartz®, and Hyalgan® )
- Xolair® (omalizumab)
If you are interested in having a registered nurse Health Coach work with your Independence Blue Cross (IBC) 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 prescription drugs that require prior authorization. More information about this process is available on the prior authorization page.
Order paper copies of manuals, newsletters, directories, health and wellness materials, and more. 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.
To receive the latest news and information of interest to the IBC provider community by email, participating providers can complete this form.
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.
NaviNet® is a registered trademark of NaviNet, Inc., an independent company.