Forms

Member Forms

Claim Form English Spanish
Use this claim form to request reimbursement for applicable medical expenses incurred for services not directly billed to the plan.

Coordination of Benefits Questionnaire English
If you or your dependents are covered under more than one medical plan, the plans will work together to coordinate the benefits you receive. To determine if Coordination of Benefits is available and appropriate, Blue Cross and Blue Shield of Illinois may ask you to complete the Coordination of Benefits Questionnaire.

HIPAA Confidential Communications Request English Spanish
Use this form to request Blue Cross and Blue Shield of Illinois or one its Business Associates to communicate with you at an alternative location or by alternative means or to terminate or modify a previously granted Confidential Communication request.

HIPAA Standard Authorization Form with Instructions English Spanish
Complete and submit this form to allow the disclosure of your Personal Health Information to any specific person or entity.

Reimbursement for Travel Form English
Use this form to submit claims for travel reimbursement

Provider Forms

Applied Behavior Analysis (ABA) Clinical Service Request
This request will need to be completed for the first ABA session along with the Member Treatment Schedule.

Applied Behavior Analysis Initial Assessment Request
This request will need to be completed for ongoing ABA sessions along with the Member Treatment Schedule. This form is to be used after the initial form and initial visit have been completed.

Coordination of Care
This request is to provide member treatment information to another treating provider or request member treatment information from another treating provider. This form is available as an option but providers may use their own Coordination of Care Form if they choose.

Electroconvulsive Therapy (ECT) Request
This request is for a clinical review if ECT meets the medical necessity definition under the member's benefit health plan.

Intensive Outpatient Program (IOP) Request
This request is for a clinical review if the IOP treatment meets the medical necessity definition under the member's health benefit plan.

Predetermination Request
This request is for verification of benefits, prior to rendering services, that may be considered experimental, investigational, or cosmetic. Approvals and denials are based on approved Medical Policies.

Psychological/Neuropsychological Testing Request
This request is for a clinical review if Psychological or Neuropsychological testing meets the medical necessity definition under the member's benefit health plan.

Repetitive Transcranial Magnetic Stimulation (rTMS)
This request is for a clinical review if rTMS meets the medical necessity under the member's health benefit plan.