Miscellaneous Forms

Last Updated: Monday, December 18, 2023

On this page, you will find some recommended forms that providers may use when communicating with Highmark, its members or other providers in the network.

Assignment of Major Medical Claim Form

Authorization for Behavioral Health Providers to Release Medical Information

Discharge Notification Form

Expanded Provider Directory - Group

Expanded Provider Directory - Practitioner

Guide to Sexual History Taking

Long-Term Acute Care Facility (Initial or Continued Stay) Worksheet (Commercial or Medicare Advantage)

Patient Treatment Summary Communication Form

PWK (Paperwork) Supplemental Claim Information Cover Sheet

Inpatient Rehabilitation (Initial or Continued Stay) Worksheet (Commercial)

Return of Monies

Skilled Nursing Facility Continued Stay Worksheet (Commercial)

Skilled Nursing Facility Precertification (Initial) Worksheet (Commercial)

Waiver of Liability Statement

Appeals Forms

Designation of Authorized Representative Form

Designation of Authorized Representative - Managed Care (HMO) Complaints

Designation of Authorized Representative Form - Medicare Advantage

Physician Certification for Expedited Review Form

Request for Independent External Review of an Adverse Benefit Determination

Notice of Medicare Non-Coverage (Freedom Blue PPO Members)

Here you will find the Notice of Medicare Non-Coverage (NOMNC) form that skilled nursing facilities, home health agencies and CORFs must deliver to Medicare Advantage patients no later than two days before services will end.

Notice of Medicare Non-Coverage (Freedom Blue PPO Members)

Detailed Notice Of Discharge (Freedom Blue PPO Members)

Detailed Notice of Discharge - Freedom Blue PPO members

®Blue Shield and the Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies.

The following entities serve central and southeastern Pennsylvania and are independent licensees of the Blue Cross Blue Shield Association: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies