Login
Hassle-free Administration.


Login
Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements
View requirements for Local Plan members.

Enter
Find a Doctor
Search our online provider directory when you need a doctor, hospital or other health care provider.
Enter

Download Commonly Used Forms and Quick Guides

PW_AD067655

General Forms
 
Advance Patient Notification Form  
 
Advance Patient Notification Form - Spanish Version  
 
COB Questionnaire 
 
EDI Registration Form 
 
Empire Non Covered Services Waiver 
 
Empire’s National Provider Identification (NPI) Registration Form  
 
FEP Outpatient Treatment Report (OTR) Form  
 
General Fax Authorization  
 
Individual Provider Billing Address Update Form  
 
Individual Provider Record Update Form  
 
Individual Provider Tax ID Update Form 
 
Managed Care Referral Form  
 
Medical Record Submission Form  
 
Notice of Denial of Medical Coverage  
 
Obstetrical Fax Authorization  
 
Physician Online Services Account Unlock Form  
 
Plan B PAB Fax Form  
 
Primary Care Physician (PCP) Patient Coverage Waiver  
 
Proton Pump Inhibitors Quantity Fax Form  
 
Refund Check Information Form  
 
Specialist Patient Coverage Waiver  
 
   
 

Utilization Management
  
Medical-Surgical Clinical Data Submission Tools 
  

Specialty Pharmacy Forms
 
Abraxane  
 
Alimta  

Aloxi  

Aranesp  
 
Avastin® (bevacizumab)  
 
Botox  
  
Campath  

Eloxatin  

Enbrel  
  
Epogen_Procrit  
 
Erbitux® (cetuximab)  
 
Faslodex  

Flolan-Remodulin 
 
Herceptin® (trastuzumab)  
 
Humira  
  
Hyaluronan Injections for Musculoskeletal Conditions 
 
Immune Globulin  
  
Leukine/Prokine  
 
Lucentis  
  
Macugen  
  
Myobloc  
  
Neulasta  

Neupogen  

Novantrone  

Orcenia  
 
Prialt® (ziconotide) Intrathecal Infusion  
 
Proleukin 
 
Remicade  
 
Rituxan  

Rocephin® (ceftriaxone) for Lyme Disease  
 
Stelera 
 
Synagis  
  
Vectibix™ (panitumumab)  
 
Velcade  

Vidaza  

   
 
 

Pharmacy Forms
 
5-Alpha-Reductase Inhibitors  
 
Abilify  
 
Actemra  
 
Actiq  
 
Activella  
 
Adcirca  
 
ADHD Narcolepsy  
 
Afinitor 
 
Aldara  
 
Alora  
 
Ambien CR  
 
Amevive  
 
Anadrol  
 
Androgens  
 
Android  
 
Androxy  
 
Antifungal Oral Therapy  
 
Apidra 
 
Arixtra  
 
Arthrotec  
 
Atrovent  
 
Avelox Quantity Supply  
 
Avonex  
 
Aygestin  
 
Azelex  
 
Beconase AQ 
 
Benzoyl Peroxide  
 
Betaseron  
 
Brand NSA  
 
Bravelle  
 
Bronchodilators  
 
Cardura XL  
 
Caverject  
 
Cenestin  
 
Cetrotide  
 
Cialis  
 
Cipro  
 
Ciprofloxacin  
 
Climara and Climara Pro  
 
Clobex 
 
Clomiphene Citrate  
 
Clozaril  
 
CombiPatch  
 
Combivent  
 
Copaxone  
 
Crinone  
 
Depo-Provera  
 
Dexilant 
 
Diabetic Test Strips  
 
Divegel  
 
Edex  
 
Edluar  
 
Elestrin  
 
Elidel and Protopic  
 
Eligard  
 
Endometrin  
 
Epiduo 
 
Erectile Dysfunction  
 
Estrace  
 
Estraderm  
 
Euflexxa  
 
Evamist  
 
Exjade  
 
FazaClo  
 
FemHRT  
 
Fentora  
 
Firmagon  
 
Flector 
 
Flomax  
 
Flonase  
 
Follistim AQ  
 
Ganirelix  
 
Gaucher Medications 
 
Geodon  
 
Gleevec  
 
GnRH Analogs  
 
Gonal-F  
 
Gonal-F RFF  
 
Haldol  
 
Hepatitis B Interferon Antiviral Therapy  
 
Hepatitis B Oral Agents Dup Tx  
 
HP Acthar  
 
Hyalgan  
 
Increlex  
 
Infergen  
 
Infertility Medications  
 
Invega  
 
Isotretinoin  
 
Kineret  
 
Kytril  
 
Levaquin  
 
Levitra  
 
Lotronex  
 
Low Molecular Weight Haparins  
 
Loxapine  
 
Lunesta  
 
Lupron Depot  
 
Lupron Depot Ped  
 
Luveris  
 
Lyrica  
 
Mellaril  
 
Menest  
 
Menopur  
 
Migranal Nasal Spray  
 
Moban  
 
Multisource Brand Medications  
 
Muse  
 
Naglazyme  
 
Narcotic Analgesics  
 
Nasacort AQ  
 
Nasal Corticosteroid  
 
Nasarel  
 
Nasonex 
 
Navane  
 
Neumega  
 
Nexavar  
 
Non Preferred benzoyl peroxide-clindamycin  
 
Non Preferred Doxycycline 
 
Non Preferred Minocycline 
 
Non Preferred NSA  
 
Non Preferred Ophthalmic Allergy  
 
Non-Preferred Statins 
 
Noroxin  
 
Novarel  
 
Nuvigil  
 
Ofloxacin  
 
Oforta  
 
Ogen  
 
Omnaris  
 
Onsolis  
 
Ophthalmic Allergy Quanity Only  
 
Orap  
 
Ortho-EST  
 
Ovidrel  
 
Oxandrin  
 
Pegylated Interferons  
 
Penlac  
 
Pregnyl  
 
Prochieve  
 
Prolixin  
 
Promethazine  
 
Prometrium  
 
Prometrium  
 
Prostacyclins  
 
Proton Pump Inhibitors (PPI)  
 
Proton Pump Inhibitors (PPI) Quantity Supply 
 
Provera  
 
Provigil  
 
Psychotropics  
 
Pulmozyme  
 
Qualaquin  
 
Quantity Limitation Override Request Form  
 
Raptiva  
 
Rebif  
 
Repronex  
 
Revlimid  
 
Rhinocort 
 
Risperdal  
 
Roferon-A/Intron-A  
 
Rosac  
 
Rozerem  
 
Saphris Seroquel  
 
Sildenafil  
 
Sodium Sulfacetamide-Sulfur Containing Products  
 
Spiriva  
 
Sprycel  
 
Stelara  
 
Stelazine  
 
Subutex  
 
Sumycin  
 
Supartz  
 
Supprelin  
 
Sutent  
 
Synarel  
 
Synvisc  
 
Synvisc-One  
 
Tadalafil  
 
Tarceva  
 
Targretin  
 
Tasigna  
 
Temodar  
 
Testred  
 
Thalomid  
 
Thorazine  
 
Toradol  
 
Trelstart Depot or LA  
 
Triptans Quantity Supply  
 
Tykerb  
 
Uloric 
 
Vantas  
 
Veramyst  
 
Vfend  
 
Viadur  
 
Victoza 

Vivelle  
 
Votrient  
 
Votrient  
 
Vytorin  
 
Xeloda  
 
Xifaxan 

Zavesca 
 
Zetia  
 
Zoladex  
 
Zolinza  
 
Zyprexa  
 
Zyvox  
 
 

Behavioral Health
 
Outpatient Treatment Report  
 
Individual Authorization Form  
 
Provider Maintenance Form  
 
Provider Specialty Profile  
 
Psychological Testing Authorization Form  
 
Psychotherapy Notes Authorization Form  
 
 

Quick Guides
 
Empire Fastcheck IVR Guide for Medical Providers  
 
Empire Fastcheck IVR Guide for Hospital Providers  
 
Institutional Quick Guide  
 
Professional Quick Guide  
 

The documents on this page are available in Adobe Acrobat format. Adobe Acrobat can be downloaded here.

 
©2009 Empire BlueCross BlueShield

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, serving residents and businesses in the 28 eastern and southeastern counties of New York State. All external sites will open in a new browser window. Please view our Website Privacy Policy for more information.