Provider Supply Line Order Form

Please complete this form to request items that you need in your office to assist you in seamlessly working with and treating your patients, our members.

Your request will be processed and delivered within five to seven business days.

* Indicates a required field.

Contact Information

* First Name: « Required

* Last Name: « Required

* Title: « Required

Provider/Office Information

* Provider/Office Name: « Required

* Street Address 1: « Required

Street Address 2:

* City: « Required

* State: « Required

* ZIP: « Required

* County: « Required

* NPI or 10-digit ID: « Required

* Phone Number: « Required

Would you like to receive email communications that announce the latest information, including Partners in Health Update^SM and provider news alerts?

Yes
No

Please select the items you wish to request.

Directories

Keystone Health Plan East and Point-of-Service (POS):

Personal Choice^® Provider Directory:

Health and Wellness Material

2011-12 Clinical Insights: Effective Care for Patients with Chronic Conditions:

2011-12 Clinical Practice Guideline Summary:

Connections^SM Health Management Programs 2011 Annual Update:

Manuals

Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers:

Provider Manual for Participating Professional Providers:

QIPS Program Manual — Measurement Year 2012 (for PA PCPs only):

QIPS Program Manual — Measurement Year 2011 (for PA PCPs only):

QIPS Program Manual — Measurement Year 2010 (for PA PCPs only):

Newsletters

Partners in Health Update^SM — issued monthly
Request #1:

Request #2:

Request #3:

Inside IPP — issued quarterly:

Provider Publication Cumulative Index — issued annually since 2002:

OB/GYN supplies

Baby BluePrints^® Initial Maternity Patient Questionnaire — 75/pack:

Baby BluePrints return envelopes for Initial Maternity Patient Questionnaire — 75/pack:

Stickers

Allergy stickers — 10 sheets (210 stickers)/pack:

Missed appointment stickers — 10 sheets (210 stickers)/pack:

Other materials, including forms and patient resources, are available at:

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.

If you still don’t see what you are looking for, or if you need to order larger quantities, please contact the Provider Supply Line at 1-800-858-4728.

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.