Fax us this form when a hospice patient has been or may be denied a medication at the pharmacy, or to communicate a beneficiary’s change in hospice status.
Use this form to grant Blue Cross and Blue Shield of Massachusetts permission to make a single disclosure of specific information to a specific person when that disclosure is not otherwise allowed by law.
This is a Mass Collaborative form. Note: for contractual changes, please use the appropriate Contract Update form. For more information, go to the Maintaining & Changing Status page in Office Resources>Enrollment (login required).
Ancillary institutional providers use this form to notify us of contractual or non-contractual changes.