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Blue Cross Blue Shield of Arizona Provider Change Form 2026
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- Click ‘Get Form’ to open the Blue Cross Blue Shield of Arizona Provider Change Form in our platform.
- Begin by filling out your provider name and degree at the top of the form. Ensure that you include your NPI and date of birth for identification.
- Indicate the type of change you are making by checking the appropriate box: Phone/Address Change, Provider Change, Tax ID Change, or Last Name Change.
- Complete the sections for primary and secondary specialties, including whether you are board certified. Provide your effective date for these changes.
- Fill in your business email, website, primary phone number, and address where services are performed. Make sure to specify if you are accepting new patients and if you want to be included in the provider directory.
- For billing and mailing addresses, provide all necessary details along with effective dates. If applicable, list any additional offices or medical records locations.
- Finally, authorize the form by entering your name in the electronic signature field and submit it via email or fax as indicated at the bottom of the form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2015 | 4.8 Satisfied (81 Votes) |
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