Professional Fee Schedule Request Online Form - Austin

 
  * Indicates a required field
National Provider Identifier (NPI) Number(s):  
* Tax Identification Number:  
* Provider Name:  
* Primary Specialty:  
* Address:  
* City/ State/Zip:  
* County:  
* Provider Office Phone Number: Ex: ###-###-####
* Contact Name:  
* Contact Phone Number: Ex: ###-###-####
* Contact Fax: Ex: ###-###-####
* Contact E-mail:  
* Product:

 BlueChoiceSM

      Facility Non - Facility

 Blue Advantage HMOSM

      Facility Non - Facility

 Blue Medicare Advantage (PPO)SM

      Facility Non - Facility

 Blue Medicare Advantage (HMO)SM

      Facility Non - Facility

 Blue EssentialsSM

      Facility   Non - Facility

 Blue PremierSM Texas

      Facility   Non - Facility

 MyBlue HealthSM (Travis and Williamson Counties Only) effective 1/1/2022

      Facility Non - Facility

 ParPlan

      Facility   Non - Facility

 Blue High Performance NetworkSM (BlueHPN)SM

      Facility  Non - Facility

* Fee Schedule Effective Date :
 
Note: Enter day followed by comma (i.e., for September 1, 2021: enter 1,)