| 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. |
Federal
Employee Program Outpatient Mental Health Treatment
Plan (PDF)
|
Form for members with FEP primary coverage. It
is not necessary to submit this form for members
with FEP secondary coverage, such as Medicare,
unless primary benefits have been exhausted, services
are not covered, or have been denied by the primary
carrier.
Call FEP Customer Service at 1 (877) 668-4654,
before treatment begins to verify the type of
coverage, benefits, eligibility, co-payments,
and deductible.
Fax completed forms to 1 (800) 331-3505. |
Behavioral
Health Treatment Plan Request
|
Treatment plan request form may be completed
using our secure and encrypted online form.
Download
(PDF),
complete the form and return to Regence:
| Fax: |
Regence
Behavioral Health 1 (800) 331-3505 |
| Mail: |
Regence BlueCross
BlueShield of Oregon
PO Box 1271, Mailstop E9H
Portland, OR 97207-9861 |
Treatment
Plan Form Instructions (PDF) |
| 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. |
Contracting and Credentialing Forms
| 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 Oregon 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 Oregon members
only as a result of members being directed to the
hospital or other inpatient setting." |
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
It is important to use the correct Regence form based upon your geographic
location. Use of another health Plan’s notification form for Regence
members is not considered valid by CMS.
| Home Health Agency |
Skilled Nursing Facility |
|
|
|
| Medical
Pre-authorization Forms |
| Form |
Description |
Instructions |
Pre-authorization
Request Form (PDF) for medical, surgical
or DME services
Pre-authorization
Information Form (PDF) for home health and
ancillary therapies
|
This form
is used when a condition requires a pre-authorization.
A limited number of services require a pre-authorization. |
- Indicate
which product the member has.
- Indicate if this is the original
request.
- Complete part II of the form, including
all procedures/HCPCS codes AND diagnosis.
- If supporting
documentation is attached, mail the form to the
address listed.
- If no supporting documentation,
fax the form to the
number(s) indicated on form.
|
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 |
| Provider
Information Update Form |
Provider
Information Update Form
|
Complete the Provider Information Update
Form using our secure and encrypted online
form. Update or change your details in our
records, including in our Provider Directories
or to submit your National Provider Identifier
(NPI). |
| Surgical
Safety Checklist |
| Surgical
Safety Checklist (PDF) |
We recommend and support the use
of this Oregon Patient Safety Commission checklist
for surgical procedures to avoid complications
and errors.
|
| Supply
request forms |
| Online
Supply
Request Form |
Request supplies such as provider
manuals, forms, brochures or patient chart stickers
using our secure and encrypted online form.
Download
the form (PDF), complete and fax to Regence
(503) 225-6911. |
Note: To print a PDF document, you need Adobe® Reader®. Download it now for free.
|
