Contract Request Online Form

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	* Indicates a required field
* National Provider Identifier (NPI) Number(s):
* Tax Identification Number:
* Provider Name:
* Primary Specialty:
Sub Specialty (if applicable):
* Address:
* City/ State/Zip:	/ /
* County:
* Provider Office Phone Number:	Ex: ###-###-####
* Contact Name:
* Contact Phone Number:	Ex: ###-###-####
* Contact Fax:	Ex: ###-###-####
* Contact E-mail:
* Agreement(s)/Contract(s) Requested:	BlueChoice® PPO/POS HMO Blue® Texas Blue Medicare PPO - preferred provider organization (PPO) plan offered to Medicare Part A and B Members in the following 5 approved Texas counties: • El Paso • Galveston – limited to the Mainland portion of Galveston county • Harris • Jefferson • Montgomery TriCare (El Paso Only)
I acknowledge that I have a valid BCBSTX Provider Record established & associated with the National Provider Identifier (NPI) Number(s) & Tax Identification Number listed above on this form.	Yes (if Yes, then click the Submit button below) No (if No, do not click the Submit button below. You will need to first contact Provider Administration at (972) 996-9610 to obtain a BCBSTX Provider Record for the NPI Number(s) and Tax Identification Number listed above