Administrative Forms

Billing and Claims Forms

• W-9 (Editable Version)
• CMS-1500 Claim
• Link to Tips for Completing the CMS-1500
• UB04 Claim
• Link to Tips for Completing the UB04
• Medicare Waiver of Liability (out of network providers ONLY)
• Out-of-Network Emergency Services and Surprise Bills (NY only)

Provider Demographic Updates/Change of Address Forms

• Are you receiving important communications from Beacon Health Options?
• Are members able to reach you for referral purposes?
• Are manual processes like faxing paperwork and filling out forms by hand taking hours out of your day?

In just a few steps, network providers can submit real time demographic updates electronically via ProviderConnect. Electronically submit demographic updates today or you may fail to receive an important communication or referral opportunity.

Beacon strongly recommends providers update their demographic information using ProviderConnect. To update active service locations, addresses, phone numbers, billing locations and other contact information, log into ProviderConnect and click on the “Update Demographic Information” link. Learn more by viewing Section 20 of the ProviderConnect User Guide.

If you have questions about a demographic update, please contact the National Provider Service Line at 800.397.1630 Monday through Friday, between 8:00 a.m. and 8:00 p.m. ET.

Provider Notification Forms

• Leave of Absence/Out-of-Office Notification Form

Credentialing

• Facility/Program Credentialing Location and Services Form
• Beacon Health Options Facility/Program Credentialing Application
• Group Addition Form
• CAQH Credentialing Frequently Asked Questions
• Provider Credentialing Criteria Checklist
• Beacon Health Options Disclosure of Ownership Form
• Beacon Health Options Attestation Participation Statement Form
• ValueOptions^® of California, Inc. Language Capability Attestation
• Roster for ABA Paraprofessional Providers
• Facility Roster
• Group Practice Roster
• Group Practice Tip Sheet
• Provider Amendment Request Form
• Site Information Change Form
• Clinician Information Form
• Contract Copy Request Form
• Facility Locations and Services Form
• Change of Address Packet

ProviderConnect Forms

Please visit the Forms section of our ProviderConnect page to access forms and other ProviderConnect resources.

Member Forms

• Authorization for Beacon Health Options to Release Confidential Information
• Autorización para que Beacon Health Options (Opciones de Salud de “Beacon”) divulgue información confidencial
• Member tip sheet: What your doctor needs to know

Site Review Forms

• Facility Site Review
• Practitioner Environmental Site Review (PESR)

eServices Forms

• eServices Terms of Use and Account Authorization Form