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We require this form for credentialing and recredentialing. By signing it, you attest to the accuracy of the information in your credentialing application and consent to the release of information we need to evaluate your request. The form must be dated within 180 days of your request.

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

This form is completed by providers and members (who have an HMO, PPO, EPO, or Indemnity health plan) when a health care provider leaves the network.

Providers and members complete this form to request continued care at certain higher-cost facilities, and pay lower costs for services, for up to one year.

For Dental Blue 65 members, use the Dental Blue 65 Enhanced Dental Benefit Enrollment Form.

Use this form ONLY for habilitative services. Habilitation services are defined as health care services that help a person keep, learn, or improve skills and functioning for daily living.

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.

Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.

Submit this form when credentialing or recedentialing to attest that you maintain the required minimum professional liability (malpractice) insurance of $1M/$3M coverage.

Use this application if you would like to bill for the technical component of X-rays, ophthalmic A scans, and limited/follow-up obstetrical ultrasounds.

For Medicare prior authorization or formulary exception requests

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.

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

The Request for Claim Review form is the final page in the guide. The guide and form were created by the MassCollaborative.

This is a Mass Collaborative form. Note: for contractual changes, please use the appropriate Contract Update form. For more information, go to Maintaining & Changing Status.

Use this application if you would like to bill for the technical component of any diagnostic imaging modality.

Ancillary institutional providers use this form to notify us of contractual or non-contractual changes.

Ancillary institutional providers use this form to notify us of contractual or non-contractual changes.