Medical forms for Medicare Advantage and Medicare Advantage Rx plans
Use these forms for Medicare Advantage and Medicare Advantage Rx plan members only.
- Appointment of Representative [pdf]
- Medicare Advantage Provider Claim Review Request Form [pdf]
- Guidelines for Bundling Admissions[pdf]
- Medical Records Routing Form - BlueMedicare [pdf]
- Medical Records Routing Form – HA MA [pdf]
- Medicare Outpatient Observation Notice (MOON) [pdf]
- Notice of Medicare Non-Coverage [pdf]
- Waiver of Liability [pdf]
- Arkansas Blue Medicare Organizational Determination Form [pdf]
- Medicare Out of Network Exception Form [pdf]
Medicare Advantage Part D
For more information about Medicare Part D (Pharmacy covered medications) plan formularies, utilization management criteria, and coverage determination requests:
2021 Medicare Advantage Prior Authorization
Dental forms for all plans
Use these forms for all members who have dental plans.
- Dental Provider Application [pdf]
If joining a clinic, also complete the Dental Authorization Form for Clinic/Group Billing.
- Dental Authorization Form for Clinic/Group Billing [pdf]
Use for notification that a practitioner is joining a clinic or group.
- Dental Provider Change of Data Form [pdf]
Use to report a change of address or other data. Completion of this form DOES NOT create any network participation.
- Member Dental claim form [pdf]
- Termination Form for Clinic/Group Billing [pdf]
- New Clinic/Group Application [pdf]
Use for NEW clinic or NEW billing group only. Not for current providers.
- Accident Form for Dental Injury [pdf]
Please use this form to file a claim with your medical plan. Accidents are not covered under your dental policy.