Provider Forms
Direct Deposit Payment
Authorize claims payment via direct deposit to your bank account.
Telemedicine Services
Use this form to let us know if your practice offers telemedicine services.
Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.
Professional Claim Adjustment Request
Use this form to file an adjustment or report an over payment to a professional claim.
Institutional Claim Adjustment Request
Use this form to file an adjustment or report an over payment to an institutional claim.
Other Coverage Questionnaire
This form is used to verify the health care coverage of your patients and to assist you in determining primary and secondary coverage.
Practice / Office Information
Use this form to update provider or office contact information with BCBSWY.
Prior Authorization Request
This form may be used by a health care provider to notify BCBSWY of a patient’s intent to receive services requiring prior certification.
Voluntary Refund Request
Use this form to submit a voluntary refund request for dates of service January 1, 2019 and prior.
No Surprises Price Negotiation
This form is used to request a price negotiation as outlined under No Surprises Act.
Dental Continuation of Care Request Form
This form contains important information about your dental health care provider’s status.
