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This form is for Individual/Group providers only. If you are a Facility/Ancillary provider please use the Contracting/Provider Information Form Facility/Ancillary(FIF) found under Quick Links in the Forms and Resources section.

Instructions for filling out this form:

There are five sections to the Credentialing Application which must be completed for each provider. They are:

  • General Information
  • Provider Demographics
  • Provider Education
  • Provider Questionnaire
  • Attestation
  • Confirmation

Please note!! A user ID and password is not required and there is not an opportunity to save this information unless you complete the application. Please verify all data prior to continuing to the next page.Please do not use your internet browser Back arrow as all your data will be lost. After 60 minutes of inactivity, your session will time out and all information entered will not be saved.

BCBSAZ and TRICARE contracting and credentialing standards require that BCBSAZ obtain, among other things, personal information, such as your name, address, and social security number. Personal information is maintained in contracting and credentialing databases by BCBSAZ for in-house tracking, reporting purposes, contracting, credentialing and payment of claims. Providing the required personal information is voluntary; however, failure to provide it will delay the contracting and credentialing process and may preclude a contract.

You have the right to review information submitted by or from other sources in support of your credentialing application, and to correct erroneous information.

**If you are submitting this application for a Group, please note upon selecting the Submit button, the prompt to Add Another Provider will be presented in order to capture the personal demographics for each provider in the group.**

IN ORDER TO COMPLETE THE ONLINE PIF, YOU MUST HAVE AN NPI. IF YOU DO NOT HAVE AN NPI, PLEASE USE THE PIF LOCATED UNDER QUICK LINKS "FORMS AND RESOURCES" AND FAX COMPLETED FORM TO 602-864-3142. ALL REQUIRED FIELDS MUST BE COMPLETED TO CONTINUE PROCESSING.

General Information

I am requesting:
*  
Are you requesting for:
*  
Electronic Provider? *  
Provider Website URL:
Office Contact:
*Contact Name:  
*Phone#:      
* Fax#:      
*Email:    
Primary Address:
*Street:  
Suite:
*City:     *State:    
*Zip:    
*Phone#:      
*Fax#:      
*Email:    
Office Hrs: to
Tip: Type 'A' or 'P' to switch AM/PM
Is this office located in a gym/fitness center?  
Do you provide the following services:



Mailing Address:
(All correspondence will be sent to this address)
* Is mailing address the same as primary address?
 
Billing Service:
* Do you use a billing service?
Additional Office Address:
Number of additional offices
If you have additional offices, simply click on the Additional Office button
 
 
Please verify that all required fields are complete and avoid the use of the “Back Arrow” browser feature, as this will result with lost data entered.