BCBSTX Contract/Agreement
Network Participation Online Request Form for Facility Based Pathology

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

* Select network(s) you are interested in:

BlueChoice® PPO/POS
Blue Advantage HMOSM
Blue Medicare Advantage
HMO Blue® Texas
ParPlan

Practicing Sub-Specialty:
(if applicable)

* Please select the category or categories that best describe(s) your practice:

 Solo Physician
 Solo Health Care Professional
 Medical Group
 Health Care Professional Group

* Provider name:

Name to be listed on contract/agreement
(if different from above):

Is the provider indicated above being added to an existing Group Contract/Agreement?

 Yes    No

Is this request for a new contract/agreement?

 Yes    No

* Tax ID #:

Additional Tax ID #:
(if applicable)

* Type 1 NPI Number:
(Note: If you do not have a Type 1 NPI Number,
visit the NPI website )

Group name:

Type 2 NPI Number:
(Note: If you do not have a Type 2 NPI Number,
visit the NPI website )

If mid-level provider, list supervising or sponsoring physician's name:
(if applicable)

Name(s) of Primary Facility/Facilities:

Minority and Women-owned Business Enterprise (MWBE) Certified?:

 Yes    No

In the event we have questions regarding this request,
who do we contact?

* Contact name:

* Contact E-mail Address:

* Contact Phone Number:


Ex: 123-456-7890

Contact Fax Number:


Ex: 123-456-7890

* Contact City, State:

Comments or additional information:

    


05/2013