Provider Other Party Liability Form

All fields are required except where noted

BCBSKS Member First Name

BCBSKS Member Middle Initial

BCBSKS Member Last Name

Member ID Number

Provider Name

Patient First Name

Patient Middle Initial

Patient Last Name

Blue Cross and Blue Shield of Kansas verifies whether or not our members have duplicate coverage. To ensure timely claims processing, please answer the following:

Is the member, or any family member, enrolled in other health insurance (not Medicare, SRS/Medicaid) for medical or dental expenses?


We also attempt to verify if injuries, carpel tunnel, heart attacks, hernias and back problems are eligible to be covered by worker's compensation or auto insurance. If the visit is related to an injury or one of the conditions described above, please answer the following questions.

Is there an accident or onset of symptoms?


Coordinating benefits places responsibility with the proper carrier, which helps keep rates lower for our customers.