Provider Change Form - Blue Cross Blue Shield Arizona Advantage Page 2
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1
2INCLUDE CHANGES IN PROVIDER DIRECTORY:
Include
Exclude
___ ___/___ ___/___ ___
Effective Date of Change
BILLING
Street:____________________________________________________________Suite #_________
ADDRESS:
City:________________________________State:___________Zip:__________________
(Contracted provider
payments will be sent to
Business E-Mail:______________________________________________________________
this address)
Phone: (
)______________________ Fax: (
)_________________
___ ___/___ ___/___ ___
Effective Date of Change
MAILING
Street:___________________________________________________________Suite #__________
ADDRESS:
City:________________________________State:___________Zip:__________________
(All correspondence will
be sent to this address)
Phone: (
)______________________ Fax (
)______________________
___ ___/___ ___/___ ___
Effective Date of Change
MEDICAL RECORDS:
Street:____________________________________________________________Suite #:_________
If different than primary
City:_____________________________State:_____Zip:________________
location)
Phone: (
) ____________________
Fax:
(
)____________________
Email: ____________________________________________________________
___ ___/___ ___/___ ___
Effective Date of Change
ADDITIONAL
Street:___________________________________________________________Suite #
__________
OFFICE(S)
City:________________________________State:___________Zip:
________________
__
(Indicate other additional
offices on an attached
Phone:
(
) _____________________
_
Fax:
(
)
___________________
sheet, if necessary)
Authorization/Referral Fax: (
)
_________________
Office Hours:
______________________________________________________________
HOSPITAL /FREE STANDING SURGERY FACILITIES PRIVILEGES:
(Indicate other additional privileges on an attached sheet)
_________________________________________________________________
ACTIVE
COURTESY
DELIVERY
PROVISIONAL
_________________________________________________________________
ACTIVE
COURTESY
DELIVERY
PROVISIONAL
ASC PRIVILEGES:_______________________________________________________________________________________
Additional Change Information/Comments:
Authorized Electronic Signature: I am _________________________, and I verify that I am authorized to submit this change form on
behalf of the provider or provider’s agent. I agree that by entering my name in the electronic signature field below, I am authorizing the
changes in this form.
/s/___________________________________________________
___________
Authorized Electronic Signature
Date
SUBMIT FORM by email to:
or fax to: BCBSAZ Advantage Provider
Relations (480) 684-7871
Questions: (480) 684-7712
–
Revision date 08/25/14
Blue Cross Blue Shield of Arizona Advantage
An independent licensee of Blue Cross and Blue Shield Association
2
ID ADV_330_2015
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