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Forms for Providers
Forms for Providers
Use the links below to print/view copies of our most frequently used forms. Forms marked as "East" apply to the Central New York, Central New York Southern Tier and Utica regions.
  • Administration
  • Medicare Incentives Claim Form (for Individual and Group Providers)
  • Durable Medical Equipment Upgrade Form
  • Patient End-stage Renal Disease Form
  • Patient Financial Responsibility Agreement Form
  • Primary Care Provider Selection Form
  • Prenatal Incentive Program Form
  • Ancillary Services
  • Outpatient Treatment Report for Chemical Dependency
  • Outpatient Treatment Report for Mental Health
  • Chiropractic Medical Record Documentation Standards East
  • Chiropractic Treatment Plan East
  • Benefits Management
  • Group Therapy Format Description Form - (includes Group Therapy Proposal Summary)
  • DBT Group Therapy Format Description Form - (includes Group Therapy Proposal Summary)
  • Easy Care Referral Form
  • Referral Fax Form
  • Request for Reconsideration Form - COB Unclear
  • Member Care Management Program Referral Form
  • Billing and Remittance
  • PaySpan Health Registration Code Request
  • APC Pricing Dispute Form
  • Claim Adjustment or Retraction Request Form
  • Provider Remittance Questionnaire
  • Coordination of Benefits Questionnaire
  • DRG Review Request Form
  • No-Fault, Workers Compensation and Medicare Exhausted Benefits Form
  • Request for Timely Filing Review
  • Overpayment Return Form
  • Request for Out-of-Area Member Claim Appeal (BlueCard)
  • Analysis and Recovery Audit - Provider Request for Review Form -
  • Brochures
  • Educational Resources Order Form
  • Parent Package on 15 Adolescent Topics
  • Clinical Editing
  • Clinical Editing Review Request Form
  • Clinical Editing Questions and Answers
  • Dental Claim Forms
  • Provider Submitted Dental Claim Form
  • Customer Submitted Dental Claim Form
  • Practitioner Enrollment
  • Applications for Enrollment and Demographic Changes
  • Disclosure of Ownership and Controlling Interest Statement