Provider Inquiry Form

Provider Inquiry Form
Requestor Name

First NameLast Name
Requestor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ext
Extension
Provider and/or Facility Name
Provider Tax ID Number
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Group Number
Group Number
ID
Member ID Number
Member Name

First NameLast Name
Member Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of Service(s)
Type of Inquiry
Place of Service
Is the provider contracted with the local Blue Cross / Blue Shield?
**If you’re requesting benefits for injections/infusions, chemotherapy, or radiation therapy, please contact Customer Service by calling the number on the back of the member’s ID card.**
Description of service / procedure (written description, no coding).
Description of diagnosis / chief complaint (written description, no coding)

100 Characters Max0/100
**Incomplete information will result in a rejection of request**
Claim number
Total Charged Amount
Please call customer service: 800-578-3272
Comments

50 Characters Max0/50
Should be Empty: