Professional Fee Schedule Form - Houston | Blue Cross and Blue Shield of Texas

* 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:

BlueChoice^SM

Facility Non - Facility

Blue Advantage HMO^SM

Facility Non - Facility

Blue Medicare Advantage (PPO)^SM

Facility Non - Facility

Blue Medicare Advantage (HMO)^SM

Facility Non - Facility

Blue Essentials^SM

Facility Non - Facility

Blue Premier^SM Texas

Facility Non - Facility

MyBlue Health^SM (Harris County Only)

Facility Non - Facility

ParPlan

Facility Non - Facility

Blue High Performance Network^SM (BlueHPN)^SM

Facility Non - Facility

* Fee Schedule Effective Date :

Note: Enter day followed by comma (i.e., for September 1, 2021: enter 1,)

Professional Fee Schedule Request Online Form - Houston