Get the forms you need in one convenient place.
Future Blue Cross NC Providers
Blue Cross NC Providers
Form for Mental Health Admin / ABT Support to request authorization for continued services
Adaptive Behavior Treatment (ABT) Request for Continued Authorization
Form for Mental Health Admin / ABT Support to request authorization for initial services
Adaptive Behavior Treatment (ABT) Request for Initial Authorization
Form for Mental Health Admin / ABT Support to attest provider qualifications before providing services to Blue Cross NC members
Adaptive Behavior Treatment (ABT) Network Group/Agency Standards Attestation
Add Users or Providers to Your Blue e Account
Blue e Account Maintenance
Signing up for Blue e
Blue e Interactive Network Agreement
Streamline claims processing by having member's complete
Coordination of Benefits Questionnaire
Apply for credentialing
Complete this form for demographic changes to your practice
Sign up for electronic fund transfers
Agreements, Forms and Instructions
Join our email registry for the latest news from Blue Cross NC
Email Registry Sign-up
Document your E-Visits for reimbursement.
Notify Blue Cross NC of a change in your secured electronic channel vendor.
E-Visit Vendor Change
Complete this form to begin the provider appeal process.
Level I Appeals
Use this form to begin the appeals process for Medicare providers.
Medicare Level I Appeals
Authorization form for appeals on the member's behalf
Member Appeal Representation Authorization Form
New prescription fax order form for PrimeMail
Prime Therapeutics - Pharmacy Fax Order Form
Form to record your notes from ambulance trips.
Post Service - Ambulance Trip Sheet Form
Form to inform Blue Cross NC of the type of Allergy testing that was performed.
Post Service - Dermatology Patch Allergy Testing Form
Form to identify the clinical justification for extra dialysis sessions.
Post Service - Hemodialysis Treatment for ESRD Form
Form to attest that IONM services were administered per Blue Cross NC policy.
Post Service - Intraoperative Neurophysiologic Monitoring Form
Form to identify the clinical justification for Intraoperative Neurophysiologic Monitoring.
Post Service - Nerve Fiber Form
Form to submit claims questions in writing.
Provider/Doctor Claim Inquiry
Include this form when returning overpayments to Blue Cross NC.Streamline claims processing by having member's complete
Provider Refund Return Form
Access patient assessment and patient educational materials.
Sign-up to receive medical record request forms and return medical records to Blue Cross NC.
Post Service Medical Records Fax Sign-up Form