Forms and Resources - Provider Supply Line

Supply Line Phone Numbers 602.995.6960 1.800.232.2345 ext.6960 Questions? Call 602.864.4231 or 1.800.232.2345 ext.4231

You must be a contracted BCBSAZ Provider to request forms.
You MUST fill out all fields in this form.
Provider Last Name:

Provider First Name:

Degree:	(MD,DO,etc.)

Provider #:

Address:	(supplies are sent to this address)

City:

State:

Zip:

Requestor's Full Name:	(person filling out this request)

Requestor Phone:	(ex. 6021234567)

Email:

Please indicate the quantity of the supply item. Please allow 7-10 working days for delivery.

Quantity	General Information Guides	STOCK #
	Health Coverage Appeals Packet	55

Quantity	Provider Directories	STOCK #
	Participating Provider Directory (includes - Participating, BluePreferred, BlueChoice, Workers' Compensation, Medicare Select networks)	21
	BlueSelect Directory	24
	ASHN Directory (American Specialty Health Networks which lists the Chiropractic Network Providers for HMO members)	26

Quantity	General Forms and Supplies	STOCK #
	Provider Address Change Request Form (address, tax id., etc)	41