| Behavioral
health forms |
| Alcohol
Use Disorders Identification Test (AUDIT) (PDF) |
The Alcohol Use Disorders
Identification Test (AUDIT) was produced by the
National Institute on Alcohol Abuse and Alcoholism,
a component of the National Institutes of Health,
and is endorsed by the World Health Organization
(WHO) as a screening tool to identify heavy alcohol
use. |
| Authorization
to Disclose Protected Health Information (PDF) |
Patient authorization for health
care provider to disclose health information
pertaining to mental health treatment, claims,
and other medical information. |
Behavioral
Health Treatment Plan Request
|
Treatment plan request form may
be completed using our secure and encrypted online
form.
Download
(PDF), complete the
form and return to Regence:
| Fax: |
Regence Behavioral Health 1
(800) 331-3505 |
| Mail: |
Regence Behavioral
Health
PO BOX 1271, Mailstop E9H
Portland, OR 97207-9861 |
Treatment
Plan Form Instructions (PDF)
For treatment plan authorization questions
only, please call Behavioral Health Customer Service
1 (800) 780-7881. |
| Federal
Employee Program (FEP) Outpatient Mental Health
Treatment Plan (PDF) |
This form is only for members
with FEP primary coverage. The provider must
call FEP Customer Service 1 (877) 668-4656,
before treatment begins to verify the type of
coverage, benefits, eligibility, co-payments,
and deductible. |
| Zung
Self-Rating Depression Scale (PDF) |
The Zung Self-Rating Depression Scale
is a screening tool to identify symptoms of depression
in adults. The first page contains the screening
questions; the second page contains the scoring
key. |
|
| Claims
and billing forms |
Important
information regarding Electronic Funds Transfers
(EFT)
|
Please read this important information prior
to submitting your request for EFT.
Complete this form to
authorize funds to be deposited directly
into your bank account. Please return
the form with an original deposit slip
or voided check. |
|
| Flu Shot Clinic Reimbursement Form |
Questions on this form or other issues
regarding flu shots, please contact
Provider Customer Service at 1 (866) 699-8170. |
| Corrected
Claim - Standard Cover Sheet (PDF) |
Complete this form to file a corrected claim. Instructions:
- Attach a copy of the original claim
- Include
the claim number that needs to be corrected
- Mail
the form with corrected claim to the address
on the back of the member’s card
|
| Supporting
Documentation - Standard Cover Sheet (PDF) |
Complete this form when submitting information
to support a claim. Instructions:
- Cover sheet ensures documentation is "attached" to
the correct claim
- Expedites processing
- Mail the form with additional
documentation to the address on the back of
the member's card
|
| Coordination
of Benefits Questionnaire (PDF) |
Complete this form when members are covered
by more than one health insurance policy. This will
help us process claims correctly. |
Hospital-Based
Practitioner Information Form (PDF) |
Use this form when a provider is being added
to a hospital-based facility. Regence BlueShield
of Idaho defines Hospital Based Practitioners
as, “Practitioners who practice exclusively
within a hospital setting, meets our credentialing
and contracting criteria and provides care for
Regence BlueShield of Idaho members
only as a result of members being directed to the
hospital or other inpatient setting." |
| Standard
Referral Form (PDF) |
Complete this form (or your own) when submitting
referrals. |
| Provider
Billing Dispute and Medical Necessity or Investigational
Denial Appeal Form (PDF) |
Form used by physicians and other health care
professionals to appeal a claim payment decision.
Note: Do not use this form to submit a corrected
claim or a member appeal. |
| Overpayment
Recovery Process and Overpayment/Voucher
Deduction Request form |
Complete the Overpayment/Voucher Deduction
Request forms as outlined in the Overpayment Recovery
process. |
It is important to use the correct Regence form based upon your geographic
location. Use of another health Plan’s notification form for Regence
members is not considered valid by CMS.
