You can request contracting or credentialing by completing and sending us the appropriate form (see options below). Also use these forms to add a tax ID to your contract. To update other provider information, please use the Provider Information Change Form (login and go to “Provider Resources > Forms > Provider Information Change”). To add a line of business or request participation in another BCBSAZ network, contact your provider liaison.
Facilities, Professional Groups, and Ancillary Providers: Facility/Group/Ancillary form (also use this form to add a tax ID to your contract)
Medical Professionals: Medical Professional form (requires a CAQH Proview number and completed provider profile; also use this form to add a tax ID to your contract)
- PT/ST/OT providers must have an individual contract and if part of a group, the group must have a facility/group contract on file with us.
- Chiropractors must apply through American Specialty Health (ASH) at 1 (888) 511-2743.
- Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract Addendum.
Dental Professionals: Dental form (requires a CAQH Proview number and completed provider profile)
TriWest CCN Network (for Veterans): TriWest Medical Professional or TriWest Facility form
Note: For more information about the BCBSAZ contracting/credentialing process, check out the overview.