Forms for providers
Our most commonly used forms are available below:
- Carelon Preauthorization/RQI Request Form
- 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
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.
Use this form to request a copy of your provider contract or a provider rate/fee schedule for a specific specialty.
Forms are not used to verify member eligibility or to check the status of a claim. Instead, please use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal or call 1-800-ASK-BLUE (1-800-275-2583) to access the Provider Automated System.