Provider forms
Below are several forms commonly used by providers. To help simplify your administrative tasks, you may download and print these forms.
If electronic submission via Availity’s provider web portal is inaccessible, providers may log in to capbluecross.com to access preauthorization forms under “tools & resources.” Forms may be faxed to Capital at the number provided on the form.
Provider forms
- Applied Behavior Analysis (ABA) approval request form
- Applied Behavior Analysis (ABA) progress report form
- Authorization of designated appeals representative
- Behavioral Health Inpatient authorization request form
- Behavioral Health Outpatient authorization request form
- Behavioral Health Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form
- CHIP Consent Form
- Claim appeal
- Claim appeal (BlueCard)
- Continuity of care
- Designation of specialist as PCP
- Electronic data interchange (EDI) enrollment
- Electronic referral notification
- External review form
- Hospice control form
- Inpatient elective admission
- Letter of medical necessity
- Medicare Advantage predetermination request form — medical and surgical
- Member appeal form
- Peer to peer request form
- Potential member safety concern (PMSC) reporting form
- Prior authorization modification and date extension request
- Refund of monies form
- Request for formulary status reconsideration
- Skilled nursing visit treatment form
- Transplant request form
- TurningPoint authorization request form
- TurningPoint post service review process - instructions
- TurningPoint post service claim review form
Preauthorization specialty injectable forms
- Botulinum toxin preauthorization request form
- Denosumab oncology (Xgeva®) and osteoporosis (Prolia®) preauthorization request form
- Filgrastim preauthorization request form
- Infliximabs preauthorization request form
- Medical injectable drugs (non-drug specific) preauthorization request form
- Ocrevus™ preauthorization request form
- Pegfilgrastim preauthorization request form
- Tysabri® preauthorization request form
- Xolair® preauthorization request form