Note: Before you complete the BCBSTX Contract/Agreement Network Participation Online Request Form below, you must have obtained a BCBSTX Provider Record ID.
* Indicates a required field, if applicable
*Select network(s) you are interested in:
BlueChoice® PPO/POS HMO Blue® Texas TRICARE (El Paso Only) ParPlan
Are you applying as a:
Yes No - Primary Care Physician Yes No - Specialty Care Physician/other Professional Provider Yes No - Primary Care/Specialty Care Physician/other Professional Provider
*Practicing Specialty:
*Please select the category or categories that best describe(s) your practice:
Solo Physician Solo Health Care Professional Medical Group Health Care Professional Group Hospital or Facility Based Provider(s)
*Provider Name:
*TAX ID #:
*Type 1 NPI Number required (Note: If you do not have, visit the NPI web site ):
Group Name:
Type 2 NPI Number (Note: If you do not have, visit the NPI web site ):
Is provider indicated above being added to an existing Group Contract/Agreement?
Yes No
Is this request for a new contract/agreement?
If mid-level provider, list supervising or sponsoring physician's name (if applicable):
List Admitting Hospital Privileges (if applicable):
Name to be listed on contract/agreement (if different from above):
In the event we have questions regarding this request, who do we contact?
*Contact Name:
*Contact Phone Number:
Ex: ###-###-####
*Contact E-mail Address:
Contact Fax Number:
*City & State Where Contact Is Located:
Comments or additional information you would like to provide:
revised 06/2010
