Get Bppppo Form

The Bppppo Form is an essential document for members of the Blue Preferred Plus program who require referrals to non-network providers. This guide will provide you with clear, step-by-step instructions to effectively complete the form online.

Follow the steps to successfully fill out the Bppppo Form online.

1. Click ‘Get Form’ button to obtain the Bppppo Form and open it in your editing interface.
2. Enter the date of referral in the designated field, ensuring to specify the month, day, and year.
3. Fill in the subscriber name, including both the member's last name and first name.
4. Provide the name and address of the non-PPO practitioner, facility, or laboratory you are being referred to, including city, state, and zip code.
5. Complete the contract number and date of birth fields for the referring member.
6. Record both the referring practitioner's and facility's names and addresses, along with their contact details, including state and zip code.
7. Input identifying information, such as the BCBSM PIN and the National Provider Identifier (NPI) numbers as required.
8. Specify the reason for the referral and include the anticipated date of service or start date in the provided sections.
9. Indicate the number of visits and the expected length of treatment.
10. Complete the section for the referred practitioner or facility, selecting the location type and entering relevant dates and specific services requested.
11. Fill in the ICD-9 diagnosis code and description as necessary.
12. Ensure that all required signatures are provided, including those of the patient or authorized person, the BPP referring practitioner, and the non-BPP practitioner.
13. Once all fields are completed, save your changes. You may then choose to download, print, or share the completed form.

Take the next step and complete your Bppppo Form online today!