- Provider Website Feedback Form
We want to ensure that your online experience meets your needs.
Quality Compliance Forms
ACO Quality Compliance Forms
- Breast Cancer Screening (BCS)
- Childhood Immunizations (CIS) Combo 3
- Childhood Immunizations (CIS) Combo 10
- Chlamydia Screening in Women (CHL)
- Colorectal Cancer Screening (COL)
- Comprehensive Diabetes Care (CDC)
- Lead Screening in Children (LSC)
- Well Child 3-6 years
- Well Child Visits in 15 months (W15)
Behavioral Health Forms
- Autism Spectrum Disorder Comprehensive Evaluation Request Form
- Behavioral Health Clinical Criteria Set Request Form
- Behavioral Health Practitioner Questionnaire
- Behavioral Health Out-of-Plan Referral Review Request Form
- Mental Health Outpatient Treatment Review (OTR) Form
- Outpatient Applied Behavioral Analysis Treatment Report
- Chemical Dependency (OTR) Review Form
Patient Care Forms
- Diabetic Retinal Exam Referral Form Use this form when completing Diabetic Retinal Exam Referrals
- Durable Medical Equipment Preauthorization Form
- Health Care Proxy Form The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.
- Injectable Medication Prior Approval Medical Necessity Form This prior authorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services.
- In-Network Referral Form Fillable form for fax use.
- Health Care Services Referral Form
- Home Health Care Preauthorization Form
- Health Survey for Adolescents A brief tool to help address high priority risk behaviors and allow for dialogue between the adolescent and their health care provider.
- Lead Risk Assessment In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age.
- Med D Coverage Determination Form A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.
- Obstetrics/Gynecology Examination Report Obstetrics/Gynecology Examination Report
- Out-of-Plan Referral Review Request Form
- Preauthorization Form Elective Surgery
- Preauthorization Form: Outpatient Services
- Preauthorization Form: Transplant
- Preauthorization/Non-Formulary Medication Request Form
- Radiology UM Guide Nuclear Cardiology Addendum
- Disclosure of History Form
- Disclosure of Ownership and Control Form - Facility
- Disclosure of Ownership and Control Form - Practitioner
- New Provider Enrollment and Disclosure Form
- Nurse Practitioner Agreement/Acknowledgement
- Patient Responsibility Form A member may be responsible for services rendered without a valid referral, for non covered services, out of network services, or services that BlueShield of Northeastern New York determines in advance are not medically necessary.
- Primary Care Physician (PCP) Change Form This is a form that providers will supply to the patient/member when they are changing their PCP.
- Provider Demographic Change Form Please submit this form to our Corporate Provider File Department when adding additional office locations to your practice, or if your practice moves from its current location. Please fax the completed form to (844) 769-5876
- Request to Resolve Provider Negative Balance
- Supervision Data Form
- Provider Claim Inquiry When submitting a provider inquiry for review, please submit all materials as indicated within the form.
- Practitioner Post-Service Appeal Form Effective January 1, 2010 providers appealing claims that have been denied by the Utilization Management Department for experimental/investigational, cosmetic, or medical necessity will be required to submit a simplified Claims Appeal Form.