Forms and Documentation

Applied Behavioral Analysis/Adaptive Behavioral Treatment for Autism Spectrum Disorder (ABA/ABT) Fax Form	PDF
BetterDoctor 2022 FAQ	PDF
Blue e Account Maintenance	PDF
Blue e Interactive Network Agreement	LINK
Coordination of Benefits Questionnaire	PDF
EFT Sign-up	PDF
Electronic Solutions	PDF
Email Registry Sign-up	PDF
Enrollment Pending Claims Filing Exception Form	PDF
E-Visit Attestation	PDF
E-Visit Vendor Change	PDF
FAQ for Electronic Credentialing and Enrollment Submission	PDF
FAQ for Enrollment Pending Claims Filing Process	PDF
Level I Appeals	PDF
Medicare BH Psych Testing Form	PDF
Medicare Level I Appeals	PDF
Member Appeal Representation Authorization Form	PDF
Prime Therapeutics - Pharmacy Fax Order Form	PDF
Post Service - Ambulance Trip Sheet Form	PDF
Post Service - Dermatology Patch Allergy Testing Form	PDF
Post Service - Hemodialysis Treatment for ESRD Form	PDF
Post Service - Medical Records Fax Sign-up Form	PDF
Post Service - Intraoperative Neurophysiologic Monitoring Form	PDF
Post Service - Nerve Fiber Form	PDF
Provider/Doctor Claim Inquiry	PDF
Provider Evaluation Form	PDF
Provider Refund Return Form	PDF
Provider Toolkits	PDF

Demographic and Contact Information Demographic and Contact Information (Job Aid)	PDF PDF
Individual Practitioner Enrollment Application	LINK
Provider Group Enrollment Application	LINK
Organizational Ownership (Job Aid)	PDF
Provider Acquisition Form	LINK
Taxpayer ID Form W9 Taxpayer ID Form W9 (Job Aid)	PDF PDF
Tax Identification and Legal Names (Job Aid)	PDF
Terminations of Practitioners and Groups (Job Aid)	PDF