| Forms | Descriptions |
| Coordination of Benefits Form | |
|---|---|
| Coordination of Benefits Form (submit online) |
Use this form to notify us of new coverage, or changes to your coverage on file with another health plan, OR another Regence BlueCross BlueShield of Oregon plan. |
| Coordination of Benefits Form (print & mail-in) |
Use this form to download and mail your other coverage information to: Regence BlueCross BlueShield of Oregon P.O. Box 1271 M/S 3L Portland, OR 97207-1271 |
| Incident Report Form | |
| Incident Report (submit online) |
Your health contract contains a subrogation provision that allows us to recoup claims payments we have made for injuries or illnesses caused by a third party. If another entity or individual may be responsible for your injury or illness, you need to complete an Incident Report. Examples of the types of accidents or illnesses we need to know about include motor vehicle accidents, work-related injuries and illnesses, injuries on another person’s property (such as falling in a grocery store), defective products or machinery, and food poisoning. |
| Incident Report (print & mail-in) |
If you prefer to download and mail or fax the Incident Report, use this form. Completed reports may be faxed to (503) 220-8459 or mailed to: Regence BlueCross BlueShield of Oregon P.O. Box 1271 M/S 3B Portland, OR 97207-1271 |
| Incident Report FAQ | Here are some common questions and answers about this form. |
| Authorization for Use and Disclosure of Protected Health Information | |
| Authorization for Use and Disclosure of Protected Health Information | Use this form to authorize Regence and/or your health care provider(s) to disclose health information to a designated party for a specific purpose. |
| Prescription Medication Mail-Order Forms | |
| Now located on the RegenceRx Web site. | |
| Claim Forms | |
| Direct Member Reimbursement Form (PDF) | Use this form to submit covered medical services that require you to pay out of pocket and submit for reimbursement. |
| Member Prescription Medication Reimbursement Claim Form | Use this form to submit prescription medications that require you to pay out of pocket and submit for reimbursement, ie., double coverage or non-partipating pharmacy. |
| International Claim Form | The BlueCard International claim form is to be used to submit claims for benefits for covered services received outside the U.S., Puerto Rico, Jamaica and the U.S. Virgin Islands. |
| Case Management Forms | |
| Case Management Referral Form | Case Management is a service that is available to all members, from birth through the golden years, who may have complex or chronic medical condition(s) or event(s). Case Managers can also assist members who have a potential for future medical conditions. You may complete the online referral request form or call 1 (866) 543-5765. |
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