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)

Ambulatory Surgical Center implant itemization form (PDF, 40 KB)

Appointment of Representative form (PDF, 162 KB)

Attestation for food and produce special supplemental benefit for the chronically ill, English (PDF, 67 KB)

Attestation for food and produce special supplemental benefit for the chronically ill, Chinese Simplified (PDF, 248 KB)

Attestation for food and produce special supplemental benefit for the chronically ill, Chinese Traditional (PDF, 196 KB)

Attestation for food and produce special supplemental benefit for the chronically ill, Spanish (PDF, 129 KB)

Attestation for independence and safe mobility with AAA special supplemental benefit (PDF, 89 KB)

Blue Shield Behavioral Health Referral Form (PDF, 531 KB)

Blue Shield 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, English (PDF, 643 KB)

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)

Palliative care patient eligibility screening tool (PDF, 271 KB)

Palliative care recertification tool (PDF, 235 KB)