Forms

PDFs of our most commonly used forms are available below:

• Consent for Case Management Form
• Continuation of Care Request Form
• Clinician Collaboration Form
• Emergency Room Review Form
• FutureScripts^® Non-formulary Exception Request 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
• Provider Change Form
• 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.

Peer-to-peer 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.

Physician Referral Form

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.

Prior Authorizations

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.

Office Administration/Patient Education Resources Electronic Order Form

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.

Provider Contract or Fee Schedule

To receive the latest news and information of interest to the Independence provider community by email, participating providers can complete this form.

Provider Email Sign-up 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.