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Provider Forms

Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.

FORM
DESCRIPTION
Advance Member Notice Waiver Form
Use this form to advise a patient that the requested service is a non-covered benefit with BCBSWY.
Direct Deposit Payment
Submit this form to authorize claims payment via direct deposit to your bank account. Read guidelines
Institutional Claim Adjustment
Use this form to file an adjustment to an institutional claim. Instructions
Insurance Questionnaire
This form is used to verify the healthcare coverage of your patients and to assist you in determining primary and secondary coverage. Read guidelines
Prospective Request (Pre-certification)
This form may be used by a healthcare provider to notify BCBSWY of a patient's intent to receive services requiring prior certification.
Professional Claim Adjustment
Use this form to file an adjustment to a professional claim. Instructions
Specialty Prescription Referral
A healthcare provider may submit this form to enroll a patient in the Specialty Medication program.
Synagis® Statement of Medical Necessity for RSV
Use this form for BCBSWY authorization of Synagis for the treatment of Respiratory Syncytial Virus (RSV).
 
 

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