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        Blue Shield of California Blue Shield of California Provider Connection Homepage
        • Eligibility & benefits
          • Overview
          • Verify eligibility
          • Member rosters
          • Benefit summaries
          • Preventive health guidelines
          • HEDIS reporting
        • Authorizations
          • Overview
          • Medical authorization
          • Medical authorization status
          • Pharmacy authorization
          • Pharmacy authorization status
          • Out-of-area Blue plan members
          • Policies & guidelines
          • Authorization forms & list
        • Claims
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          • How to submit claims
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          • Claim issues & disputesNEW
            New

            File disputes online

            You can now file disputes, attach supporting documents, and retrieve letters for submitted disputes online! Available for commercial, Shared Advantage®, and BlueCard®.

            Learn more
          • Policies & guidelines
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        • Patient care forms

        Patient care forms

        Submit these forms when delivering patient care, including forms related to coordinating benefits, member grievances, and more. You'll need Adobe Reader to view the forms.

        Acknowledgement of Financial Responsibility (PDF, 115 KB)

        ASC Implant Itemization Form (PDF, 40 KB)

        Attestation for Independence and Safe Mobility with AAA Special Supplemental Benefit (PDF, 89 KB)

        BSC Promise Community Supports Referral Form (PDF, 199 KB)

        Claims Fax Coversheet (PDF, 59 KB)

        Coordination of Benefits Questionnaire (PDF, 71 KB)

        DMHC Member Grievance Form (PDF, 1.5 MB)

        DMHC Cancellation of Health Coverage Grievance Form (PDF, 243 KB)

        DOI Member Grievance (PDF, 976 KB)

        Home Care Referral (PDF, 530 KB)

        Language Assistance Request (PDF, 62 KB)

        Member Advance Notice – Referral to Non-Preferred Provider (PDF, 30 KB)

        Out of Network Referral Request Form (PDF, 493 KB)

        Palliative Care Patient Eligibility Screening Tool (PDF, 449 KB)

        Palliative Care Recertification Tool (PDF, 235 KB)

        Network and procedure forms

        Download and submit Blue Shield forms that help you and your office meet credentialling requirements and other procedures.

        Find network and procedure forms

        Prior authorization forms

        Find forms you may need to submit prior authorization requests.

        Find forms for Blue Shield IFP, Small, Large Group and Medicare members

        Find forms for Blue Shield Promise, Medi-Cal members

        Policies and standards

        Find medication policies information and standards for HIPAA transactions, medical records and more.

        Read about our policies and standards

        Patient care resources and programs

        Find information to help your members, such as language assistance resources, patient education materials, member rights and responsibilities, and more.

        Find patient care resources

        Learn more about patient care programs for providers and members

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