Forms
PDFs of our most commonly used forms are available below:
Consent for Case Management Form
Continuation of Care Request Form
Clinician Collaboration Form
Dental Continuation of Care Request Form
Emergency Room Review Form
HIPAA Authorization for Disclosure of Health Information — authorizes Independence Blue Cross (Independence) 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
Member Consent for Provider to File an Appeal on my Behalf with Health Insurance Plan
Overpayment/Refund Form
Post Acute Discharge Form
Provider Change Form
Provider Network Services Inquiry Request
Request to Move Member from PCP to LTC PCP Panel
Request to Update Procedure Code(s) on an Existing Authorization Form
Surgical Team (Modifier-66) Documentation Form
The peer-to-peer process streamlines workflows, improves cost-efficiencies, and complies with accreditation requirements. To participate in the peer-to-peer process, please complete this request form.
If you are interested in having a registered nurse Health Coach work with your Independence patients, please complete a physician referral form or contact us by calling 1-800-313-8628.
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.
Order paper copies of manuals, health and wellness materials, and more. Please note that claim forms, such as the CMS-1500, are not available through the Order Form; they are available for purchase at many local office supply stores.
To receive the latest news and information of interest to the Independence 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 (NaviNet Open) or call 1-800-ASK-BLUE (1-800-275-2583) to access the Provider Automated System.
NaviNet® is a registered trademark of NantHealth, an independent company.