Miscellaneous Forms

On this page, you will find some recommended forms that providers may use when communicating with Highmark, its members or other providers in the network.

Address/Phone Number Change Form for Facility & Ancillary Providers
This form is to be used for facility/ancillary changes. Professional address changes should be completed by using the Existing Address Change Form for Professional Providers under the Provider Information Management Forms link.
Advanced Illness Services (AIS) Quarterly Report
PDF Version
Microsoft Excel Version
Assignment of Major Medical Claim Form
Authorization for Behavioral Health Providers to Release Medical Information
Bariatric Surgery Precertification Worksheet
Designation of Authorized Representative Form
Designation of Authorized Representative Form – Managed Care (HMO) Complaints
Discharge Notification Form
Expanded Provider Directory - Group
Expanded Provider Directory - Practitioner
Guide to Sexual History Taking
Highmark Clinical Services Referral Form
Highmark Facility/Ancillary Change Form
Home Health Precertification Worksheet
Inpatient Authorization Request Form
Interpreter Needed - Language Translation Sign for Provider Offices
Long-Term Acute Care Facility Precertification Form
Medical History Form (Preexisting Condition Form)
Medicare Prescription Drug Coverage Brochure Order Form
Non-Emergent Ambulance Prior Authorization form (for Medicare Advantage Members)
Outpatient Authorization Request Form
Patient Treatment Summary Communication Form
PCP/Practice Virtual Visit Member Flier
PCP Template Letter to Patients Concerning Urgent Care Centers-Retail Clinics vs. ER
PWK (Paperwork) Supplemental Claim Information Cover Sheet
Rehabilitation Precertification Worksheet
Request For Addition Of A New Drug To The Formulary
Retail Clinic Virtual Services Member Flier
Return of Monies
Short Term Blue Member Prescription Drug Claim Form
Skilled Nursing Facility Precertification Worksheet
Specialist to PCP Diabetic Retinopathy Exam Communication Form
Specialist Virtual Visit Member Flier
SilverSneakers Fitness Program Patient Information Form
(For 21-county Central Region FreedomBlue PPO and MedigapBlue Members Only)
Teledermatology Member Flier
Therapy Treatment Plan
Virtual Behavioral Health Member Flier
Waiver of Liability Statement

Notice of Medicare Non-Coverage (Freedom Blue PPO members)

Here you will find the Notice of Medicare Non-Coverage (NOMNC) form that skilled nursing facilities, home health agencies and CORFs must deliver to Medicare Advantage patients no later than two days before services will end.

Notice of Medicare Non-Coverage (Freedom Blue PPO Members)

Detailed Notice of Discharge (Freedom Blue PPO members)

Detailed Notice of Discharge - Freedom Blue PPO members

Last updated on 10/19/2020 8:20:26 AM

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

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Miscellaneous Forms

Notice of Medicare Non-Coverage (Freedom Blue PPO members)

Detailed Notice of Discharge (Freedom Blue PPO members)

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