Bristol-Myers Squibb is committed to helping appropriate patients get access to our medications by providing access and reimbursement support services.

This information is intended for U.S. healthcare professionals and/or healthcare professionals involved in healthcare reimbursement.

Forms and Resources

Video Resources

Looking for insurance information, helpful tools, or answers to common coverage questions? We’ve provided the following videos for healthcare providers and their patients.

Forms and Documents

Please select your therapeutic area.

Enrollment Forms

Oncology Enrollment Form

Download

Oncology Patient Authorization and Agreement Form (English)

Download

Oncology Patient Authorization and Agreement Form (Spanish)

Download

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Claim Documents

Blank CMS-1500 Form

Download

Blank UB-04/CMS-1450 Form

Download

Office Support Tools

Patient Benefits Information Form

Download

Medically Unlikely Edit (MUE) Appeal Template Letter

Download

Oncology Infusion Checklist

Download

Medical Necessity Template Letter*

Download

Letter of Medical Necessity Checklist

Download

Prior Authorization Denial/Redetermination Appeal Template Letter*

Download

Commercial Claim Denial Appeal/Redetermination Template Letter*

Download

Open Access Template Letter*

Download

My BMS Cases User’s Guide

Download

HCP Reimbursement Process Map

Download

*Template letters are provided as examples of potential correspondence.

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)

Download

Medicare Reconsideration Request Form (Form CMS-20033)

Download

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)

Download

Medicare Appointment of Representative Form (Form CMS-1696)

Download

Patient Resources

Understanding Your Healthcare Benefits

Download

Patient Brochure

Download

Patient Reimbursement Process Map

Download

Enrollment Form

Rheumatology Enrollment Form

Download

Rheumatology Patient Authorization and Agreement Form

Download

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Claim Documents

Blank CMS-1500 Form

Download

Blank UB-04/CMS-1450 Form

Download

Office Support Tools

Patient Benefits Information Form

Download

Medical Necessity Template Letter*

Download

Prior Authorization Denial/Redetermination Appeal Template Letter*

Download

Commercial Claim Denial Appeal/Redetermination Template Letter*

Download

Open Access Template Letter*

Download

*Template letters are provided as examples of potential correspondence.

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)

Download

Medicare Reconsideration Request Form (Form CMS-20033)

Download

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)

Download

Medicare Appointment of Representative Form (Form CMS-1696)

Download

Patient Resources

Understanding Your Healthcare Benefits

Download

Patient Brochure

Download

Patient Reimbursement Process Map

Download

Enrollment Form

Kidney Transplant Enrollment Form

Download

Kidney Transplant Patient Authorization and Agreement Form

Download

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Claim Documents

Blank CMS-1500 Form

Download

Blank UB-04/CMS-1450 Form

Download

Office Support Tools

Patient Benefits Information Form

Download

Medical Necessity Template Letter*

Download

Prior Authorization Denial/Redetermination Appeal Template Letter*

Download

Commercial Claim Denial Appeal/Redetermination Template Letter*

Download

My BMS Cases User’s Guide

Download

*Template letters are provided as examples of potential correspondence.

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)

Download

Medicare Reconsideration Request Form (Form CMS-20033)

Download

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)

Download

Medicare Appointment of Representative Form (Form CMS-1696)

Download

Patient Resources

Understanding Your Healthcare Benefits

Download

Patient Brochure

Download

Patient Reimbursement Process Map

Download

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

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Use of the information on this site is subject to the terms of our Legal Notice and Privacy Statement. The coding, coverage, and payment information contained within this website is current as of 10/20.

MMUS2002083-01-01 10/20