Provider Inquiry Form

Provider Inquiry Form
Requestor Name*

First NameLast Name
Requestor Phone Number*
Please enter a valid phone number.
Ext
Extension
Provider and/or Facility Name*
Provider Tax ID Number*
Fax Number*
Please enter a valid fax number.
Group Number*
Group Number*
ID
Member ID Number*
Member Name*

First NameLast Name
Member Date of Birth*

MonthDayYear
Date of Service(s)*
Type of Inquiry*
Place of Service*
Is the provider contracted with the local Blue Cross / Blue Shield?*

YesNo
**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: