| * 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 (Harris County Only) Facility Non - Facility ParPlan Facility Non - Facility Blue High Performance Network® (BlueHPN)® Facility Non - Facility |
|
* Fee Schedule Effective Date :
|
Note: Enter day followed by comma (i.e., for September 1, 2021: enter 1,) |
|
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