Forms for providers

Our most commonly used forms are available below:

• FEP Case Management Consent 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
• LTAC Precertification 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
• Post-Acute Facility Admission Guide
• 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

Additional resources

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 the 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.

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.

Use this form to request a copy of your provider contract or a provider rate/fee schedule for a specific specialty.

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