Welcome Provider! Company Information
BlueCross BlueShield of Texas
NPI
   
 
         
     
 


Downloadable Forms

To view a form click the name below. Our pharmacy forms are located below:

Provider Forms 
Consent to Assignment of Provider Contracts (Change of Ownership-CHOW) Request 
Claim Appeal/Reconsideration Review Request - (PDF 72kb) Interactive
Coordination of Benefits Forms 
Cranial Remolding Orthosis (CRO) Device Form - (PDF 12kb)
Credentialing / Contracting
Fee Requests 
Growth Hormone Test for Now - (PDF 7kb)
Hemophilia Referral Fax Form - (PDF 206kb) Interactive
Home Evaluation for a Power Operated Vehicle (POV) Form - (PDF 668kb) Interactive 
Immunoglobulin Therapy Request  - (PDF 12kb)
PAVETTM Evaluation Form for Microprocessor Knee
PHI Authorization Form - (PDF 81kb) Interactive
Predetermination Request - (PDF 30kb) Interactive
Provider Voluntary Refund Form - (PDF 13kb) Interactive
Remicade Predetermination Request - (PDF 149kb) Interactive
Room Rate Update Notification Form - (PDF 29kb)
Synagis Request Form
Verification Request - (PDF 109kb) Interactive
Wheelchair Medical Necessity Form - (PDF 183kb) Interactive 

 

Pharmacy Forms
Document Name
Injectable Drug List - (PDF 34kb)
Injectable Request Form - (PDF 44kb)
Quantity Limit Override Request Form - (PDF 30kb)
Quantity Limit Overrride Request Form--Proton Pump Inhibitors - (PDF 28kb)
QVT Drug List - (PDF 129kb)
QVT Brochure - (PDF 120kb)
Topical Verapamil Override Request Form - (PDF 12kb)

 

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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.
© Copyright 2008. Health Care Service Corporation. All Rights Reserved.

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