Patient care forms
Submit these forms when delivering patient care, including forms related to coordinating benefits, member grievances, and more. You'll need Adobe Reader to view the forms.
Acknowledgement of financial responsibility (PDF, 115 KB)
ASC implant itemization form (PDF, 40 KB)
Attestation for independence and safe mobility with AAA special supplemental benefit (PDF, 89 KB)
BSC Promise community supports referral form (PDF, 199 KB)
Claims fax coversheet (PDF, 59 KB)
Coordination of Benefits questionnaire (PDF, 71 KB)
DMHC member grievance form (PDF, 1.5 MB)
DMHC cancellation of health coverage grievance form (PDF, 243 KB)
DOI member grievance (PDF, 976 KB)
Home care referral (PDF, 530 KB)
Language assistance request (PDF, 62 KB)
Member advance notice – referral to non-preferred provider (PDF, 30 KB)
Out of network referral request form (PDF, 493 KB)
Palliative care patient eligibility screening tool (PDF, 449 KB)
Palliative care recertification tool (PDF, 235 KB)
Network and procedure forms
Download and submit Blue Shield forms that help you and your office meet credentialling requirements and other procedures.
Prior authorization forms
Find forms you may need to submit prior authorization requests.
Find forms for Blue Shield IFP, Small, Large Group and Medicare members
Policies and standards
Find medication policies information and standards for HIPAA transactions, medical records and more.
Patient care resources and programs
Find information to help your members, such as language assistance resources, patient education materials, member rights and responsibilities, and more.
Learn more about patient care programs for providers and members