Forms

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To make it easier to find the forms you use regularly, we’ve put them all in one place. Some forms can be submitted online, and others can be printed and then faxed or mailed to us. (There are specific instructions on each form.)

Become a Participating Provider 
Use this online form to apply for participation in our network.

Website Registration
To register as a participating provider and access our secure Provider site, you’ll need to request a provider personal identification number (PIN).

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Patient Coordination of Benefit
To process claims timely and accurately, it’s important that we know if a patient has any health insurance coverage other than Blue Cross & Blue Shield of Rhode Island. If your patient has other coverage, please complete this form. You can fax it to (401) 459-1137 or mail it to:
 
Attn: Provider COB – 00043
Blue Cross & Blue Shield of Rhode Island
500 Exchange Street
Providence, RI 02903
 
Please note: In addition to completing the form, you can attach a photocopy of the front and back of the other health insurance card. This will help improve processing of the form.
CMS-1500 (02-12) Form Completion Informational Guide

This guide is designed to help you when completing the CMS-1500 (02-12) form.

Case Management Referral Form

Please complete this form to refer a member for case management services.

W-9

Form for providing taxpayer identification number and certification for federal reporting purposes.

CMS-1500 (08-05) Form Completion Informational Guide

This guide is designed to help you when completing the CMS-1500 (08-05) form.

Behavioral Health Provider Practice Information Survey

By taking part in this survey, you’re helping ensure that our members have the most up-to-date information about your practice.

Primary Care/Behavioral Health Communication Form

This form is designed to increase communication and provide care coordination between behavioral health and primary care providers.

Practitioner Change Form

Please use this form to notify us of any changes to your practice.