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Forms

Behavioral health forms
Alcohol Use Disorders Identification Test (AUDIT) (PDF)

The Alcohol Use Disorders Identification Test (AUDIT) was produced by the National Institute on Alcohol Abuse and Alcoholism, a component of the National Institutes of Health, and is endorsed by the World Health Organization (WHO) as a screening tool to identify heavy alcohol use.

Authorization to Disclose Protected Health Information (PDF)

Patient authorization for health care provider to disclose health information pertaining to mental health treatment, claims, and other medical information, to Regence.

Regence Behavioral Health Outpatient Treatment Plan Request (PDF) This form is for members with Regence BlueCross BlueShield of Utah coverage who require an authorization for behavioral health outpatient treatment. Please call Regence Behavorial Health Customer Service at 1 (800) 780-7881 for any authorization questions.
Federal Employee Program (FEP) Outpatient Mental Health Treatment Plan (PDF) This form is only for members with FEP primary coverage. Please call FEP Customer Service at 1 (877) 668-4657 before treatment begins to verify patient coverage, benefits, eligibility, co-payments, and deductible.
Zung Self-Rating Depression Scale (PDF)

The Zung Self-Rating Depression Scale, is a screening tool to identify symptoms of depression in adults. The first page contains the screening questions; the second page contains the scoring key.

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Claims and billing forms
Overpayment Recovery Process and Overpayment/Voucher Deduction Request forms

Complete the Overpayment/Voucher Deduction Request forms as outlined in the Overpayment Recovery process.

Important information regarding Electronic Funds Transfers (EFT)

Automatic Deposit (EFT/ ACH Credits) Authorization Agreement (PDF)

Please read this important information prior to submitting your request for EFT.

Complete this form to authorize funds to be deposited directly into your bank account. Please return the form with an original deposit slip or voided check.

Corrected Claim - Standard Cover Sheet (PDF)

Complete this form to facilitate the submission of a corrected claim. Submitting this form with your corrected claim will help us quickly identify this as a corrected billing and forward it on to the appropriate area for reprocessing. If available, please be certain to include the original claim number.

Completed forms should be sent to:
Regence BlueCross BlueShield of Utah
PO Box 30270
Salt Lake City UT 84130-0270

Hospital-Based Practitioner Information Form (PDF)

Use this form when a provider is being added to a hospital-based facility. Regence BlueCross BlueShield of Utah defines Hospital Based Practitioners as, “Practitioners who practice exclusively within a hospital setting, meets our credentialing and contracting criteria and provides care for Regence BlueCross BlueShield of Utah members only as a result of members being directed to the hospital or other inpatient setting."
Incident Report (PDF)

Members who need medical care as a result of an injury or accident may be asked to complete this form and submit it to Regence BlueCross BlueShield of Utah.

Instructions:
  • Check to see if the condition is one we investigate. If yes, the member will need to complete the form.
  • If the condition is one we do NOT investigate, the form is not necessary.
  • Member must complete and sign the form.
  • Do not copy completed form and send in for every claim.
  • Submit the form only when requested- see voucher for message code indicating one is needed.
Other Insurance Information (PDF) Employees who are covered under a spouse’s health plan as well as a Regence BCBSU plan, or a Regence HealthWise plan, or a Regence ValueCare plan should complete this form and mail it to Regence BCBSU.
Coordination of Benefits Questionnaire (PDF) Complete this form when members are covered by more than one health insurance policy. This will help us process claims correctly.
Required Information Review (PDF) This form must be used by Home Health agencies to pre-authorize services and supplies or request any visit or duration extensions for members. Fax completed forms along with any supporting documentation to (801) 333-6511.
Standard Referral Form (PDF) Your office can use the Community Health Information Technology Alliance (CHITA) Standard Referral Form or your own, when submitting referrals.
Supporting Documentation - Standard Cover Sheet (PDF) This is a standard cover sheet for submitting medical information in support of a claim. Supporting documentation may be required (such as when billing an unlisted procedure code), or may be requested for review of a previously submitted claim. Using this cover sheet will ensure that documentation is “attached” to the right claim(s) and will expedite processing.

If we are requesting additional information, please call Customer Service prior to submitting documentation to clarify what information is needed. Information not requiring medical review, such as an onset date, can be accepted over the phone. If documentation is required, please be certain to include the claim number for accurate processing.

Completed forms should be sent to:
Regence BlueCross BlueShield of Utah
PO Box 30270
Salt Lake City UT 84130-0270

Provider Billing Dispute and Medical Necessity or Investigational Denial Appeal Form (PDF) Form used by physicians and other health care professionals to appeal a claim payment decision. Note: Do not use this form to submit a corrected claim or a member appeal.

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Hospital-Based Practitioner Information Form

Hospital-Based Practitioner Information Form (PDF)

Use this form when a provider is being added to a hospital-based facility. Regence BlueCross BlueShield of Utah defines Hospital Based Practitioners as, “Practitioners who practice exclusively within a hospital setting, meets our credentialing and contracting criteria and provides care for Regence BlueCross BlueShield of Utah members only as a result of members being directed to the hospital or other inpatient setting."

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Miscellaneous forms 
Sample – Non-covered Member Consent Form (PDF)

Use this sample form as a guideline when developing a member consent form. You may wish to consult with your legal counsel before adopting this format.


Pre-authorization forms 
Pre-authorization Request Form (PDF) This form may be used to facilitate the pre-authorization process for medical, surgical or DME services.
Pre-authorization Information Form (PDF) This form may be used to facilitate the pre-authorization process for home health and ancillary therapies.

Statement of Medical Necessity for Oncotype DX (PDF)

This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999. Fax completed forms to 1 (800) 453-4341


Pharmacy forms
Medication Prior-Authorization Forms Now located on the RegenceRx Physician Web site.
McKesson Specialty Rx Forms Now located on the RegenceRx Physician Web site.

Provider Information Update Form

Provider Information Update Form

This form may be submitted online.

Provider Information Update Form (PDF)

Use this form to update or change your details in our records, including in our Provider Directories. You can also submit your National Provider Identifier (NPI) to Regence using this form.

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Medicare Forms

Hospital discharge notice
The An Important Message From Medicare About Your Rights form, along with additional information can be obtained from the Centers for Medicare & Medicaid Services (CMS).

Notice of Medicare Non-Coverage (NOMNC) forms for home health and skilled nursing facilities

It is important to use the correct Regence form based upon your geographic location. Use of another health Plans notification form for Regence members is not considered valid by CMS.

Home Health Agency Skilled Nursing Facility

Note: To print a PDF document, you need Adobe® Reader®. Download it now for free.