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BlueCross BlueShield of Texas
   
 
         
     
 


Downloadable Forms

There are three categories of forms available for your use - General, Medical Policy & Pharmacy. Please locate the form you need below and then click on the offering.

General Forms 
Document Name
Claim Appeal/Reconsideration Review Request Interactive
Consent to Assignment of Provider Contracts (Change of Ownership-CHOW) Request
Coordination of Benefits
Corneal Transplant Predetermination Request
Credentialing / Contracting
Dependent Student Medical Leave Certification Form
Fee Requests 
Hemophilia Referral Fax  Interactive
PHI Authorization  Interactive
Predetermination Request  Interactive
Provider Voluntary Refund  Interactive
Room Rate Update Notification 
Verification Request  Interactive
Medical Policy Forms (Note: May be used as a supplement to medical record documentation)
Document Name
Bariatric Surgery Interactive
Cranial Remolding Orthosis (CRO) Device Interactive
Growth Hormone Interactive
Hyperbaric Oxygen (HBO) Pressurization Interactive
Immunoglobulin Therapy Interactive
Oncotype DX Interactive
PAVETTM Evaluation for Microprocessor Knee Interactive
Remicade  Interactive 
Synagis & RSV
Varicose Vein Management  Interactive  
Wheelchair Medical Necessity and Home Evaluation Verification  Interactive  
Pharmacy Forms
Document Name
Triessent Speciality List 
Triessent Prescription/Pharmacy Intake 
Quantity Limit Override Request 
QVT Drug List 
QVT Brochure 
Topical Verapamil Override Request 

 

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A Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the
Blue Cross and Blue Shield Association.
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