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.

Enrollment Form Tutorial

Helping patients enroll for support programs can present unique challenges. Watch this video and learn about the enrollment process for BMS Access Support.

This video is intended for HCPs.

Enrollment Form Tutorial

This video is intended for HCPs.

What is an Explanation of Benefits (EOB)?

This video is intended for your patients.

What is Health Insurance?

This video is intended for your patients.

Forms and Documents

Please select your therapeutic area.

Enrollment Form

Download the Oncology Enrollment Form

Oncology Patient Authorization and Agreement Form (English)

Oncology Patient Authorization and Agreement Form (Spanish)

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

Claim Documents

Blank CMS-1500 Form

Blank UB-04/CMS-1450 Form

Office Support Tools

Patient Benefits Information Form

Medically Unlikely Edit (MUE) Appeal Template Letter

Oncology Infusion Checklist

Medical Necessity Template Letter*

Letter of Medical Necessity Checklist

Prior Authorization Denial/Redetermination Appeal Template Letter*

Commercial Claim Denial Appeal/Redetermination Template Letter*

Open Access Template Letter*

My BMS Cases User’s Guide

HCP Reimbursement Process Map

*Template letters are provided as examples of potential correspondence.

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

Claim Documents

Blank CMS-1500 Form

Blank UB-04/CMS-1450 Form

Office Support Tools

Patient Benefits Information Form

Medical Necessity Template Letter*

Prior Authorization Denial/Redetermination Appeal Template Letter*

Commercial Claim Denial Appeal/Redetermination Template Letter*

Open Access Template Letter*

*Template letters are provided as examples of potential correspondence.

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)

Medicare Reconsideration Request Form (Form CMS-20033)

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

Medicare Appointment of Representative Form (Form CMS-1696)

Patient Resources

Understanding Your Healthcare Benefits

Patient Brochure

Patient Reimbursement Process Map

Enrollment Form

Download the Kidney Transplant Enrollment Form

Kidney Transplant Patient Authorization and Agreement Form

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

Claim Documents

Blank CMS-1500 Form

Blank UB-04/CMS-1450 Form

Office Support Tools

Patient Benefits Information Form

Medical Necessity Template Letter*

Prior Authorization Denial/Redetermination Appeal Template Letter*

Commercial Claim Denial Appeal/Redetermination Template Letter*

My BMS Cases User’s Guide

*Template letters are provided as examples of potential correspondence.

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)

Medicare Reconsideration Request Form (Form CMS-20033)

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

Medicare Appointment of Representative Form (Form CMS-1696)

Patient Resources

Understanding Your Healthcare Benefits

Patient Brochure

Patient Reimbursement Process Map

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.