Have you registered with CAQH?*
Have you completed all the necessary steps below to enable BCBSAZ to access and review your universal CAQH application? *
Contact information for questions related to this application:
Provider Information
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
Do you have an active DEA Registration Number?
What are your practicing specialties?
Are you participating as a PCP under the above tax ID? *
This participation impacts accuracy of cost share for services provided.
Are you Medication-assisted Treatment (MAT) Certified? *
Are you accepting new patients? *
This information will be noted in our provider directory.
Are you an Indian health service provider with the federal health program for American Indians and Alaska Natives? *
Are you interested in participating in our Medicare Advantage network? *
Do you (physician, not the staff) speak any languages other than English?
This request applies to (check one or both):*
Practice Information
Hospital/Freestanding Surgery Facility Privileges
Group Information
Does your group have a concierge practice? *
Contact person for the practice (practice administrator/office manager) for business correspondence:
Contracts and correspondence must be sent to the provider, not a billing company or a consultant.
Primary Office Information
Primary address must be a physical location in Arizona, where services are performed.
Office Hours
Select the days and hours that your primary office is open:
All Other Addresses
Billing Address:
Mailing Address:
Medical Records Address:
Credentialing Address:
Additional Office Information
Do you have another location where you actively practice on a regular basis, under the same Tax ID?
Select the days and hours that your secondary office is open:
Attach Supporting Documents