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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
Credentialing / Contracting
Facility Out-of-Network Care Enrollee Notification Interactive  Interactive
Fee Requests 
Hemophilia Referral Fax  Interactive
PHI Authorization  Interactive
Predetermination Request  Interactive
Provider Voluntary Refund  Interactive
Room Rate Update Notification Form 
Verification Request  Interactive
Medical Policy Forms (Note: May be used as a supplement to medical record documentation)
Document Name
Cranial Remolding Orthosis (CRO) Device Interactive
Growth Hormone Interactive
Immunoglobulin Therapy Interactive
Oncotype DX Interactive
PAVETTM Evaluation for Microprocessor Knee Interactive
Remicade  Interactive 
Surgery for Morbid Obesity Interactive Interactive
Synagis
Varicose Vein Management  Interactive 
Wheelchair Medical Necessity and Home Evaluation Verification  Interactive 
Pharmacy Forms
Document Name
Triessent Speciality List 
Triessent Prescription/Pharmacy Intake Form 
Quantity Limit Override Request Form 
Quantity Limit Overrride Request Form--Proton Pump Inhibitors 
QVT Drug List 
QVT Brochure 
Topical Verapamil Override Request Form 

 

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a Mutual Legal Reserve Company, an Independent Licensee of the
Blue Cross and Blue Shield Association.
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