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/ / 1st Date of Dialysis for ESRD: / / Was ESRD started in a facility? Yes No Was ESRD started as Self Dialysis or Home Dialysis: Has a transplant been performed? Yes Yes No No If yes, please provide the date of the transplant. / / Section C If this does not apply, skip to Section D. COURT ORDER INFORMATION Is there a Court Order specifying a person(s) to maintain health coverage for any of your dependent(s)? No Yes List the name(s) of the depe.

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Fax 888-579-7935. If unable to fax, mail to: BCBSTX, P.O. Box 660044, Dallas, TX 75266-0044.

BCBSTX only accepts medical records through the Availity Portal in response to requests for additional medical record documentation used for quality and risk adjustment purposes. Administrator Instructions: Select Availity Enrollment Center > Medical Attachments Setup, then enter required data.

The Customer Advocate Department is available at 1-888-657-6061 (TTY: 711). We are open 8 a.m. to 5 p.m. Central Time, Monday through Friday. You may leave a voicemail outside of our normal business hours or on weekends and holidays.

About Blue Cross and Blue Shield of Texas BCBSTX is a Division of Health Care Service Corporation (which operates Blue Cross and Blue Shield plans in Texas, Illinois, Montana, Oklahoma and New Mexico), the country's largest customer-owned health insurer and fourth largest health insurer overall.

(282-4548) or log on to Availity. The information required to file electronic claims is the same as for paper claims but there are major advantages to submitting electronic claims versus paper claims: You have better control and accuracy.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232