Cross Blue Shield of Arizona (BCBSAZ) you must successfully complete the credentialing process. Please complete the enclosed application. 1) If you utilize CAQH, the Council for Affordable Quality Healthcare, BCBSAZ will accept that application. Please indicate your CAQH ID# in lieu of completing this entire application. CAQH ID#:______________ Then complete pages 1-3 in full. 2) If you do not have CAQH, Please complete the entire enclosed application and provide the supporting documentation a.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the AZ Provider Contracting Request and Information Form online
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.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- 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.
- 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.
- List any other names you have used, as well as the group name if applicable, in the respective fields.
- 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.
- Indicate whether you are an Indian Health Care Provider by selecting 'Yes' or 'No' in the designated section.
- Complete the licensing information by entering your Arizona license number and the date you were first licensed to practice.
- Provide your DEA number, if applicable, and other relevant identification numbers such as Medicare B number.
- 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.
- Select your specialty and taxonomy information by checking the applicable boxes and providing the required details regarding your primary and other specialties.
- If you are board certified, attach a copy of your board certificate and complete the required information regarding this certification.
- List the languages spoken by you, as well as any hospital or surgery facility privileges you hold.
- Fill in your primary and billing addresses, ensuring accuracy as this will determine where payments and notices are sent.
- 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.
- 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.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
The department has issued forms which correspond to specific contracting scenarios. Some...
The Contracting team is part of Finance & Budget that reviews, processes, supports, and...
Easily search for Member details, including eligibility status, covered benefits and...
Get answers to your most pressing questions about US Legal Forms API.
How do I email AHCCCS provider enrollment?
To email AHCCCS provider enrollment, you should send your inquiries to providerenrollment@azahcccs. This email is an excellent way to obtain detailed responses regarding the AZ Provider Contracting Request and Information Form. Ensure that you provide all necessary information in your email to expedite their response. Engaging with AHCCCS through email allows for clear communication of your enrollment questions.
What is the phone number for Health Choice of Arizona provider?
You can reach Health Choice of Arizona provider services at 1-800-322-8670. When you contact them, you can ask questions related to the AZ Provider Contracting Request and Information Form and other provider-specific topics. Their knowledgeable staff is equipped to provide you with the necessary information and support. Don't hesitate to connect with them for any guidance you may need.
What is the phone number for BCBS CA provider claims?
The phone number for BCBS California provider claims is 1-800-541-6705. If you encounter any issues regarding claims, especially when dealing with the AZ Provider Contracting Request and Information Form, this number will direct you to their claims department. Their team will help resolve your concerns efficiently, allowing you to focus on patient care. Always have your claim details ready to ensure faster assistance.
What is the phone number for Medicaid provider services in Arizona?
For Medicaid provider services in Arizona, you can call 1-800-234-5678. They provide comprehensive support for issues related to the AZ Provider Contracting Request and Information Form. This service is designed to help providers navigate Medicaid-related processes smoothly. Be sure to have your provider number handy when you call to streamline your inquiry.
Is the Blue Cross Blue Shield of Arizona the same as the Blue Cross Blue Shield?
Yes, Blue Cross Blue Shield of Arizona (BCBSAZ) is part of the larger Blue Cross Blue Shield system, but each operates independently. Therefore, BCBSAZ may have specific guidelines and processes, particularly concerning the AZ Provider Contracting Request and Information Form. It's important to refer to the resources specific to Arizona to get the most relevant information for your practice. Understanding these distinctions can enhance your provider experience.
What is the phone number for BCBS of Arizona provider services?
The phone number for BCBS of Arizona provider services is 1-866-286-5573. By calling this number, you can obtain assistance with the AZ Provider Contracting Request and Information Form. Their team is dedicated to ensuring that providers like you receive timely and effective support for all your inquiries regarding contracting. Don't hesitate to reach out for clarifications and detailed assistance.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.
This form is available in several versions. Select the version you need from the drop-down list below.