Forms - Arkansas Blue Cross and Blue Shield

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Forms for Providers

The forms listed on the menu below are for use by medical providers. These forms are in portable document format (PDF) and allow you to complete the form online, print, sign and mail to the appropriate address with supporting documents. Contact your Network Development Representative at the Office Location nearest you for assistance.

Authorization Form for Clinic/Group Billing (PDF) — Use for notification that a practitioner is joining a clinic or group.
Claim Reconsideration Request Form (PDF)
Medicare Coverage Determination Request (PDF)
Medicare Part D 2012 Prior Authorization Criteria – Medi-Pak Advantage (PFFS) MA-PD (PDF)
Medicare Part D 2012 Prior Authorization Criteria – Medi-Pak Advantage (PPO) MA-PD (PDF)
Medicare Part D 2012 Prior Authorization Criteria – Medi-Pak Rx Basic (PDF)
Medicare Part D 2012 Prior Authorization Criteria – Medi-Pak Rx Premier (PDF)
Medicare Part D Prior Authorization Forms
Notice of Payer Policies and Procedures and Terms and Conditions (PDF) — Applicable to all individual network participants and applicants.
Patient Waiver Form (PDF) — Use to educate members on services that may not meet the Primary Coverage Criteria of the member’s policy. Waivers allows providers to collect for services that may not be deemed as meeting the Primary Coverage Criteria particularly for services designated as experimental/investigational or which are not for the treatment of a medical condition.
Pharmacy Forms for Medications that have Quantity Limits
Physician/Supplier Corrected Bill Submission Form (PDF) — Use when submitting previously finalized (corrected) bills.
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.
Provider Refund Form (PDF) — Use this form to submit a claim refund.
Termination Form for Clinic/Group Billing (PDF) — Use for notification that a practitioner is leaving a clinic.

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Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.
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