Request Form For Verification
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1Request for Verification
Please complete this form in its entirety. Any omitted fields (other than the optional information) will result in this request being
incomplete and unable to be processed.
Date of Request: _________________
Patient name: _______________________________________________
Patient ID number: ___________________________________________ (HMO = 11 digits, all other 9 digits)
Patient date of birth: _________________
Name of enrollee or subscriber: _________________________________
Enrollee or Subscriber ID number: _______________________________
Patient relationship to Enrollee or Subscriber (check one):
Self
Spouse
Child
Grandchild
Other
Presumptive diagnosis: ______________ or presenting symptoms: ________________________________________________
Procedure code(s): ________ _________ ________ or description of proposed procedure(s): ______________________
Place of service (if other than provider’s office or location, name of Hospital or Facility where proposed services will be provided):
__________________________________________________
Proposed date(s) of service: _______________ - _______________
Group number: _______________
If known to the provider, name and contact information of any other carriers:
a) Carrier’s name: ________________________
b) Carrier’s address: ___________________________________
c) Carrier’s telephone number: (_____) _____-_________
d) Name of enrollee: ______________________________
e) Plan or ID number: _____________________________
f) Group number: ________________________________
g) Group name: __________________________________
Name of provider providing the proposed service: ______________________________
Please provide the following additional information in order to expedite your request:
National Provider Identifier (NPI) Number(s): ____________________________
If already obtained, precertification and/or referral number for proposed services: ____________________
Please mail completed form to the following address:
BCBSTX or HMO Blue Texas
Request for Verification
P.O. Box 833908
Richardson, Texas 75083
Upon completion of processing, written requests for verification will receive a written notice via U.S. Mail.
*Written requests for verification will only be accepted at this designated P.O. Box address. Verification requests mailed to any other
address will not be accepted. In addition, this P.O. Box may not be used for claims filing or any other correspondence.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Rev. 05/2008
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