If you do not already have a provider record set-up with Blue Cross and Blue Shield of Texas (BCBSTX), please complete the following form:

• Solo Provider Record Information Form 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.

Special Note: Obtaining a provider record does not mean you are a participating provider in the BlueChoice or HMO Blue Texas provider network - you must complete the application process described in the Credentialing/Recredentialing Process.

Should you have any questions, please call Provider Administration at (972) 996-9610.