ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Notice of Medicare Non-Coverage (NOMNC) (PDF)
လံာ်တီလံာ်မီတဖၣ်ဒီး လံာ်ကွီၣ်ဒိတဖၣ်အစၢတဖၣ်
တၢ်ပာ်ဖျါ 1141 - 1150 လၢ 3159 အစၢတဖၣ်အကျါ
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Cost Estimate Form Provider services (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Cost Estimate Request Form Hospital and Facility Services (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Member Requested Authorization for Release of Information for Blue Cross (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Notice of Denial of Medicare Coverage (NDMC) Platinum Blue (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Notice of Denial of Medicare Coverage (NDMC) SecureBlue (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Authorization Cancellation for Blue Cross (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Authorization Cancellation for Blue Plus (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Individual Commercial Change Form (PDF)
ကသံၣ်ကသီပှၤဟ့ၣ်မၤစၢၤတၢ်
Notice of Medicare Non-Coverage (NOMNC) SecureBlue (PDF)