Forms and Documentation

Get The Forms You Need In One Convenient Place

Provider Setup & Enrollment Changes
Demographic and Contact Information 
Demographic and Contact Information (Job Aid) 
PDF
PDF
Individual Practitioner Enrollment Application  LINK
Provider Group Enrollment Application  LINK
Organizational Ownership (Job Aid)  PDF
Provider Acquisition Form LINK
Taxpayer ID Form W9 
Taxpayer ID Form W9 (Job Aid)
PDF
PDF
Tax Identification and Legal Names (Job Aid)  PDF
Terminations of Practitioners and Groups (Job Aid)  PDF

Other Forms & Documents
Applied Behavioral Analysis/Adaptive Behavioral Treatment for Autism Spectrum Disorder (ABA/ABT) Fax Form PDF
BetterDoctor 2022 FAQ PDF
Blue e Account Maintenance PDF
Blue e Interactive Network Agreement LINK
Coordination of Benefits Questionnaire PDF
Credentialing PDF
EFT Sign-up PDF
Electronic Solutions PDF
Email Registry Sign-up PDF
Enrollment Pending Claims Filing Exception Form PDF
E-Visit Attestation PDF
E-Visit Vendor Change PDF
FAQ for Electronic Credentialing and Enrollment Submission PDF
FAQ for Enrollment Pending Claims Filing Process PDF
Level I Appeals PDF
Medicare BH Psych Testing Form PDF
Medicare Level I Appeals PDF
Member Appeal Representation Authorization Form PDF
Prime Therapeutics - Pharmacy Fax Order Form PDF
Post Service - Ambulance Trip Sheet Form PDF
Post Service - Dermatology Patch Allergy Testing Form PDF
Post Service - Hemodialysis Treatment for ESRD Form PDF
Post Service - Medical Records Fax Sign-up Form PDF
Post Service - Intraoperative Neurophysiologic Monitoring Form PDF
Post Service - Nerve Fiber Form PDF
Provider/Doctor Claim Inquiry PDF
Provider Refund Return Form PDF
Provider Toolkits PDF

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