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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Provider Information section. Enter the Servicing Provider/Vendor/Lab’s Name and Address, Tax ID Number, NPI, and Referring/Prescribing Physician’s Name.
Next, complete the Patient Information section. Input the Patient’s Name, Birth Date, and Blue Shield ID Number. Indicate whether the patient is a PCP or Specialist and specify the specialty.
In the Patient Clinical Information section, ensure you check all required boxes and provide necessary documentation as indicated. This includes entering ICD-10 codes and CPT/HCPCS codes where applicable.
Finally, review all entries for accuracy before submitting. Use our platform's features to save your progress or share it directly with relevant parties for further action.

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