- BCBSAZ.ProviderCredentialing.WebUI

Have you registered with CAQH?*

Yes, I've registered with CAQH

No, I haven't registered with CAQH

CAQH Provider ID *

Have you completed all the necessary steps below to enable BCBSAZ to access and review your universal CAQH application? *

Uploaded supporting documentation in the CAQH profile/application
Confirmed that my certificate is current and will not expire in the next 30 days
Attested to the CAQH Application
Verified that my credentialing information, including the current practice address, is current
Authorized BCBSAZ to access my CAQH application

Yes, I’ve completed all the steps listed above.

No, I haven’t completed all the steps listed above.

Contact information for questions related to this application:

First Name*

Last Name*

Phone Number*

Ext.

Preferred way to contact

Email Address *

Preferred way to contact

Provider Information

* Indicates required fields

First Name *

Last Name *

Middle Initial

Other First Name

Other Last Name

Middle Initial

Date of Birth *

Social Security Number *

Gender *

Female

Male

Degree (MD, DO, etc.) *

Please note: State law requires PA and PAC providers to have a supervising physician on file. Please provider a supervising physician name and degree.

Supervising Physician Information

First Name *

Last Name *

Degree (MD, DO, etc.) *

Individual NPI *

Effective Date *

Tax ID *

Date You Started Billing With This Tax ID *

License *

Date You Were Licensed to Practice in AZ *

Do you have an active DEA Registration Number?

Yes, I have an active DEA Registration Number.

DEA Registration *

Expiration Date *

No, I don't have an active DEA Registration Number.

What are your practicing specialties?

Please note: You'll be listed in the BCBSAZ provider directories by your practicing specialty(s).

Primary Practicing Specialty *

Other Practicing Specialty(s), as Applicable

Are you participating as a PCP under the above tax ID? *

This participation impacts accuracy of cost share for services provided.

Yes, I am.

No, I am not.

Are you Medication-assisted Treatment (MAT) Certified? *

Yes, I am.

No, I am not.

Are you accepting new patients? *

This information will be noted in our provider directory.

Yes, I'm accepting new patients.

No, I'm not accepting new patients at this time.

Are you an Indian health service provider with the federal health program for American Indians and Alaska Natives? *

Yes, I am.

No, I am not.

Are you interested in participating in our Medicare Advantage network? *

Yes, I am.

No, I am not.

Do you (physician, not the staff) speak any languages other than English?

Yes, I speak the following language(s).

No, I do not speak any other languages.

This request applies to (check one or both):*

BCBSAZ Network Participation

TriWest Healthcare Alliance Network Participation

Practice Information

* Indicates required fields

Hospital/Freestanding Surgery Facility Privileges

Facility Name

Group Information

Group's Legal Name *

Group's Doing-Business-As (DBA) Name

Group/Organization NPI *

Effective Date *

Date You Were Licensed to Practice in AZ *

Does your group have a concierge practice? *

Yes, it does (Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract).

No, it doesn't.

Contact person for the practice (practice administrator/office manager) for business correspondence:

Name *

Email Address *

Phone *

Fax

Contracts and correspondence must be sent to the provider, not a billing company or a consultant.

Business Website Address *

Business Email Address *

Primary Office Information

* Indicates required fields

Primary address must be a physical location in Arizona, where services are performed.

Address *

City *

State *

ZIP Code *

Phone (Patient Scheduling Number) *

Fax *

Email Address *

Office Hours

Select the days and hours that your primary office is open:

All Other Addresses

* Indicates required fields

Primary Address:

Use same for billing

Use same for mailing

Use same for medical records

Use same for credentialing

Billing Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Mailing Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Medical Records Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Credentialing Address:

Address *

City *

State *

ZIP Code *

Phone *

Fax *

Email Address *

Additional Office Information

* Indicates required fields

Do you have another location where you actively practice on a regular basis, under the same Tax ID?

Do not include locations where you work occasionally or cover for other providers

Yes, I've got another office.

No, I don't have another office.

Address *

City *

State *

ZIP Code *

Phone (Patient Scheduling Number) *

Fax *

Email Address *

Office Hours

Select the days and hours that your secondary office is open:

Same office hours as primary office

Additional Information/Comments

Attach Supporting Documents

(Supporting documents: Certificate of Insurance, Copy of Professional License, Curriculum Vitae and DEA Certificate
Accepted file type PDF or JPG)

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Authorized Electronic Provider Signature

Signature *

Date *