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Administrative

File Name Line(s) of Business Format
Ancillary Request to Participate all lines of business external site
Contract Copy Request Form all lines of business PDF
Electronic Funds Transfer Registration Instructions all lines of business PDF
Electronic Remittance Advice Request Instructions and FAQs all lines of business PDF
Fee Schedule Request Form all lines of business PDF
Hospital, Ancillary Facility, and Supplier Business Application all lines of business external site
Medicare Advantage Waiver of Liability Form for Non-Contracted Providers Medicare PDF
Member Discharge from PCP Practice (HMO and BlueMedicare HMO only) Commercial, Medicare PDF
National Provider Identifier (NPI) Notification Request Commercial, Medicare external site
Notice of Medicare Non-Coverage Form and Instructions Medicare PDF
Panel Status Change Request Commercial, Medicare external site
Physician and Group Request to Participate  all lines of business external site
Provider Registration  all lines of business external site

Update Provider Information

all lines of business external site

Appeals

File Name Line(s) of Business Format
Non-Contracted Medicare Advantage Appeal Form Medicare PDF
Provider Clinical Appeal Instructions and Form all lines of business PDF
Provider Reconsideration/Administrative Appeal Instructions Form all lines of business PDF

Claims & Billing

File Name Line(s) of Business Format
Billing Authorization for Provider Groups all lines of business external site
Claim Overpayment Refund Form all lines of business PDF
Independent Dispute Resolution Process: Open Negotiation Notice and Form Commercial, Federal Employee Program PDF
BCBCA Coordination of Benefits Questionnaire BlueCard PDF

Coordination of Patient Care

Pharmacy

File Name Line(s) of Business Format
Accredo Prescription Enrollment Form Commercial, Medicare PDF
Contraceptive Tier Exception Request Instructions Commercial FB site
CoverMyMeds  all lines of business external site
CVS Caremark Hemophilia Enrollment Form all lines of business PDF
CVS Caremark Specialty Pharmacy Enrollment Form  all lines of business PDF
Dispense As Written (DAW) Penalty Waiver Request Form Commercial PDF
Skilled Nursing Facility Select Medication Program Order Form all lines of business PDF

Quality Care

Member Forms

Florida Blue members can access a variety of forms including: medical claims, vision claims and reimbursement forms, prescription drug forms, coverage and premium payment and personal information.

Medicare Plans

Forms for Florida Blue Medicare members enrolled in BlueMedicare plans (Part C and Part D) and Medicare Supplement plans.

Individual, Family & Employer Plans (non-Medicare)

Forms for Florida Blue members enrolled in individual, family and employer plans.