For Dental Blue 65 members, use the Dental Blue 65 Enhanced Dental Benefit Enrollment Form.
Fax this form to our Medicare Pharmacy Operations team at 1-866-463-7700 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 Maintaining & Changing Status.
Institutional providers use this form to notify us of contractual or non-contractual changes. To add an individual clinician to your contract, please use a form for professional providers (above).