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Access forms for providers
Click on the applicable form, complete online, print, and then mail or fax it to us.
Provider Forms
- 835 Health Care Electronic Remittance Advice Request Form (PDF)
- Accredo Prescription Enrollment Form (PDF)
- Adult Problem List (PDF)
- Ancillary Request to Participate Form (external site)
- Billing Authorization for Professional Associations (external website)
- Care Management Referral Form (PDF)
- Claim Overpayment Refund Form (PDF)
- Clinical Care Referral Form (PDF)
- Continuity of Care Form (PDF)
- Contraceptive Tier Exception Form (PDF)
- Contraceptive Tier Exception Request Instructions
- Contract Request Form (PDF)
- Coverage Protocol Exemption Form (PDF)
- Coverage Protocol Exemption Instructions
- CoverMyMeds (external website)
- CVS Caremark Hemophilia Enrollment Form (PDF)
- CVS Caremark Specialty Pharmacy Enrollment Form (PDF)
- Electronic Funds Transfer Registration Form (PDF)
- Facility Care Management Referral Form (PDF)
- Fee Schedule Request Form (PDF)
- Hospital, Ancillary Facility and Supplier Business Application (external website)
- Independent Dispute Resolution 30-Day Negotiation Request Form (PDF)
- Medicare Advantage Waiver of Liability Form for Non-Contracted Providers (PDF)
- Medicare Clinical Care Programs Referral Form (PDF)
- Member Discharge from PCP Practice (HMO and BlueMedicare HMO only) (PDF)
- National Provider Identifier (NPI) Notification Form (external website)
- Non-Par Medicare Advantage Appeal form (PDF)
- Notice of Medicare Non Coverage Form (PDF)
- Notice of Medicare Non Coverage Form Instructions (PDF)
- Panel Status Change Request Form (esternal website)
- Pediatric/Adolescent Problem List (PDF)
- Physician and Group Request to Participate Form (external website)
- Preservice Fax Cover Sheet for Medical Records (PDF)
- Provider Clinical Appeal Form (PDF)
- Provider Reconsideration/Administrative Appeal Form (PDF)
- Provider Information Update Form (external website)
- Provider Registration Form (external website)
- Skilled Nursing Facility Select Medication Program Order Form (PDF)
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.