Forms

Thank you for browsing our provider forms. If you have any questions or comments about the forms, please contact us.

Coordination of Benefits

• Coordination of Benefits/Blue Cross and Blue Shield of Alabama is host plan

Enrollment

• Add a New Provider Location Online or Print the Application to Add a New Provider Location
• Ancillary Network Application
  • Preferred Durable Medical Equipment (DME) Supplier Invitation
  • Preferred Home Health Provider Invitation
  • Preferred Hospice Agency Invitation
• Common Pay Number
• Contract Request Form
• Disclosures to Business Associates of Health Care Providers
• E-mail Notification Service
• Non PMD Provider Application
• Participating Chiropractic Application
• Provider Change Notification
• PRP New Physician Notification
• Taxpayer Identification Number Request Form W-9

Medical

• Blue Advantage Precertification Form
• Chiropractors Certification Form
• Disease Management Direct Referral Form
• DME Certificate of Medical Necessity
• Non-Covered Services Statement for Occupational Therapists
• Non-Covered Services Statement for Physical Therapists
• PCN Retro-Referral
• Physical Therapy Precertification
• Provider Appeals
• Specialty Pharmacy
• Voluntary Overpayment Return

Pharmacy

• Blue Advantage Physician Drug Authorization Request Form
• BlueRx Physician Drug Authorization Request Form
• Cimzia Prescription Drug Authorization Request Form
• Compound Coverage Authorization Request Form
• Controlled Substance Drug Authorization Request Form
• General Prescription Drug Authorization Request Form
• Enbrel® Prescription Drug Authorization Request Form
• Humira® Prescription Drug Authorization Request Form
• Kineret® Prescription Drug Authorization Request Form
• Medication Therapy Management Claim Form
• Pegasys® Prescription Drug Authorization Request Form
• Simponi® Prescription Drug Authorization Request Form
• Suboxone®/Subutex® Prescription Drug Authorization Request Form
• Synagis® Authorization Request Form

Precertification

• Blue Advantage Precertification Form
• Chiropractors Certification Form
• CT Scan Precertification Form
• DME Certificate of Medical Necessity
• FEP Hospice Request for Certification
• Home Health Request for Certification
• Hospice Certification Form
• LTAC Pre-Admission Evaluation Form
• MRI Scan Precertification Form
• Occupational Therapy Precertification Review
• PET Scan Precertification Form
• Physical Therapy Precertification
• Provider Appeals

Electronic Data Interchange (EDI)

• Customer Service Toll-Free Access Agreement
• Electronic Funds Transfer (EFT) Authorization Agreement

Dental

• Dental Provider Application

Psychiatric

• Authorization for Disclosure of Mental Health Clinical Information
• Psychiatric Case Management Prescreening
• Psychiatric Outpatient Certification
• Psychiatric Substance Abuse Certification
• Psychiatric Substance Abuse CSR