Requesting a Provider Record from BCBSTX does not mean you are a network participating provider. 

• If you do not already have a Provider Record set-up with BCBSTX, please complete one of the following packets: 

Solo Provider Record Information Form Packet 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
• A provider who is not incorporated

Group Provider Record Information Form Packet 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
• If the billing entity is incorporated
• To add a provider to an existing group, use the Group Member Information Form on page 3 of the Group Provider Record Information Form

Forward completed Provider Record Form Packet to:

Fax to: 972-996-8445 (preferred method)

 

or

Mail to:
Blue Cross and Blue Shield of Texas
Provider Administration
P.O. Box 650267

Dallas, TX 75265-0267

• If you need the status of a previously submitted Provider Record Information Form Packet or have questions regarding the completion of the Provider Record Information Form Packet, please contact Provider Administration at (972) 996-9610.
• Once you have received notice of your established Provider Record and would like to be a participating provider, please continue with Option 2.

Revised 09/2009