For your convenience, we have outlined the steps necessary to make applications to BlueChoice^® and/or HMO Blue^® Texas networks. You may find it beneficial to read through these steps in their entirety before accessing the link to obtain the form.

The first step to join the BlueChoice and/or HMO Blue Texas networks is to contact Provider Administration to ensure you have a provider record set- up with Blue Cross and Blue Shield of Texas (BCBSTX).

If you do not already have a record or would like to confirm the information on your record, please contact Provider Administration at
(972) 996-9610.

Special Note: Requesting a record from BCBSTX does not mean you are a participating provider in the BlueChoice or HMO Blue Texas provider network - you must complete the application process described below and be accepted.

• If you need the status of a previously submitted Provider Record Information Form or have questions regarding the completion of the Provider Record Information Form, please contact Provider Administration at (972) 996-9610.
• If you do not already have a record set-up with BCBSTX, please complete the following form:
  • Solo Provider Record Information Form (page 1) should be completed by:
    • A provider who will not be employing another professional provider
    • A provider who will be using his/her social security number for tax purposes
    • A provider whose Tax Identification Number (TIN) is legally in the provider's name
  • Group Provider Record Information Form should be completed by:
    • A provider who has a practice with more than one professional provider
    • A provider whose federal tax ID has a corporate legal name
    Note: To add a provider to an existing group, use the Group Member Information Form on page 4.

Once you have a record set-up with BCBSTX, and if you are one of the following provider types we contract with, then complete the Texas Standardized Credentialing Application and all applicable attachments.
(CAQH Users, please contact CAQH for instructions in downloading your information to the TDI Credentialing application.)

• MDs and DOs
• DDSs (oral and maxillofacial surgery)
• Licensed Physical Therapists, Occupational Therapists,
• Optometrists, Audiologists, Speech and Language Pathologists
• Behavioral Health Providers
• Physician Assistants, Surgical Assistants, Advanced Practice Nurses, Certified Nurse Midwives, Registered Nurse First Assistants
• Podiatrists
• Chiropractors
• Acupuncturists
• Certified Registered Nurse Anesthetists

Additionally, you must complete our BCBSTX Cover Page, which needs to be submitted in conjunction with the credentialing application.

If you are a Behavioral Health Professional, the Behavioral Health Form must be completed and returned along with the application and cover page.

After completing all the required information stated above, please contact your local  Professional Provider Network office to obtain further information related to the network contracts.

updated 5/2008