Get Az Provider Contracting Request And Information Form 2013

Completing the AZ Provider Contracting Request and Information Form is an essential step in the credentialing process for providers seeking to become contracted with Blue Cross Blue Shield of Arizona (BCBSAZ). This guide offers clear, step-by-step instructions to help you navigate the form effectively and submit it online.

Follow the steps to fill out the AZ Provider Contracting Request and Information Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your provider name and degree in the designated fields. Check that your full name is recorded accurately, including last name, first name, and middle initial.
3. Provide your date of birth, social security number, and place of birth in the appropriate sections. Ensure that this information is entered correctly to prevent delays.
4. List any other names you have used, as well as the group name if applicable, in the respective fields.
5. Fill in the necessary National Provider Identifier (NPI) numbers for both your individual and group practices, as well as the tax identification number and start date for billing.
6. Indicate whether you are an Indian Health Care Provider by selecting 'Yes' or 'No' in the designated section.
7. Complete the licensing information by entering your Arizona license number and the date you were first licensed to practice.
8. Provide your DEA number, if applicable, and other relevant identification numbers such as Medicare B number.
9. Indicate your practice information, including whether you are accepting new patients, and supply your business website and email address. Remember that all correspondence will be sent to the business email provided.
10. Select your specialty and taxonomy information by checking the applicable boxes and providing the required details regarding your primary and other specialties.
11. If you are board certified, attach a copy of your board certificate and complete the required information regarding this certification.
12. List the languages spoken by you, as well as any hospital or surgery facility privileges you hold.
13. Fill in your primary and billing addresses, ensuring accuracy as this will determine where payments and notices are sent.
14. Complete the attestation section by confirming that all the provided information is accurate. Ensure that the submitter's name and signature are included with the date.
15. Review all entries for completeness and accuracy. Save changes to your document, then proceed to download or print a copy before sharing or submitting it as required.

Complete your AZ Provider Contracting Request and Information Form online today to begin the credentialing process with Blue Cross Blue Shield of Arizona.