Blue Cross Blue Shield of Texas - Provider Nomination Form

PPO Information
Any Doctor, Any Time
Out-of-Network Coverage
Coverage for a Wide Range of Services
Health Care and Emergency Care
How the BlueCard Program Works
Pharmacy
BlueCard^® Benefit

Provider Nomination Form

To nominate a physician to participate in the contracting provider network, complete the form below. Prior to submitting your nomination, check the Provider Finder or ask the provider about his/her network status. The nomination process may take up to 90 days. Providers must meet all established credentialing requirements and must agree to all contract provisions, policies and procedures. In addition, there may be other reasons why a provider will not be accepted into a network. This nomination does not in any way guarantee that the provider will be accepted into the network.

An asterisk (*) indicates a required field.

Employer Information
Employer Name*

Provider Information
Physician Name*	Last First MI
Hospital Affiliation
Specialty Type*	Family Practice	Other
	Internal Medicine	Pediatrics
Address*

City*	State* Zip*
County
Physician Office Number*
E-mail