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Request Contracts

 

Name:    Required
Title:     
NPI:   
Physical Address:   
Mailing Address:   
City:   
State:   
Zip:   
Phone:   
Fax:
Email Address:
Specialty:   
License Number:   
Tax Number:   
Social Security Number:
DEA Number (Dental Providers and Therapeutic Optometrist Only):
Other Provider's DEA Number and Name:
Networks Requested:
Contact Name:   
Contact Number:   
Send Disclosure Form: Yes
No
Send EFT/Electronic Billing Form (when sending a change form only): Yes
No

Disclaimer:
NOTE: Please note that submission of the Online Contract Request form is not confirmation that the provider will be accepted into BlueCross BlueShield of Tennessee Networks. The provider will receive an Enrollment packet that will help guide them through the enrollment process. If the provider has not received an enrollment packet within 5 – 7 business days, please contact Provider Network Services at 1-800-924-7141 and choose "Option 2" or say "Contracting".

Page Modified:September 17, 2010