Case Management Referral Form | Independence Blue Cross

By providing my phone number and/ or email address, I authorize Independence Blue Cross to contact me via email, automated text and/or phone call. I understand that my consent is not a condition of any benefit or purchase. Message and data rates may apply.

To ensure your privacy, all information will be sent via a secure connection. Independence Blue Cross will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.

Case and Condition Management Physician Referral Form

Your information

Pertinent Data

Requested Intervention

Additional information

Physician and Contact Information