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 #
Provider Operating Guide 11
Health Coverage Appeals Packet 55
Prescription Medication Guide 56
Provider Grievance Process
Provider Appeals Process
Quantity Provider Directories STOCK #
Participating Provider Directory (includes - Participating, BluePreferred, BlueChoice, Workers' Compensation, Medicare Select networks) 21
BlueSelect Directory 24
Dental Choice Directory 27
Dental Plus Directory 23
ASHN Directory (American Specialty Health Networks which lists the Chiropractic Network Providers for HMO members) 26
Quantity Provider Newsletter
Blues Letter (most current issue) 31
Quantity General Forms and Supplies
Provider Address Change Request Form (address, tax id., etc) 41
Disease Management Educational Materials Order Form 44
Notice of Excess Payment Form (hospitals only) 45
Appointment Cards 47
Provider Immunization Reminder Cards 48
Quantity General Forms and Supplies
Hospital Outpatient Claims Coding Guide (used by hospitals & ASCs only) 53
Code Edit Updates (May 2004) 54
Code Edit Updates (October 2004) 57
Code Edit Updates (December 2004) 58
Code Edit Updates (April 2005) 59
Code Edit Updates (May 2005-Dental) 60
Code Edit Updates (November 2005) 61
Code Edit Updates (May 2006) 62
Code Edit Updates (December 2006) 63
Code Edit Updates (April 2007) 64
Code Edit Updates (November 2007) 65
Code Edit Updates (April 2008) 66
Code Edit Updates (December 2008) 67