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ANCILLARY PROVIDER ID REQUEST FORM Blue Cross and 2026

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The document is an Ancillary Provider ID Request Form for Blue Cross and Blue Shield of Texas (BCBSTX), intended for establishing an Out-of-Network provider ID. It requires detailed information about the service provider, including corporate name, address, contact details, and tax identification information. The form also includes sections to indicate the provider's status in relation to a main hospital and requires signatures for verification. Additional documentation such as a facility license, W-9 form, and NPI confirmation must be attached.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date at the top of the form. This is essential for processing your request.
Fill in the 'Provider of Service Information' section with your corporate name, address, and contact details. Ensure accuracy as this information is crucial for identification.
Complete the 'Tax I.D Information' section with your Federal Tax ID number and payee address. If applicable, indicate if you are adding an affiliate location to a parent hospital.
Sign and date the form at the bottom, confirming that all provided information is accurate. Attach required documents such as your facility license, signed W-9 form, and NPI confirmation.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to credential with BCBS with CAQH?

If you are a CAQH participant, please be certain to use this standardized Provider Credentialing Intake Form and submit the form to BSCInitialApp@blueshieldca.com. If you are not a CAQH participant but would like to register with CAQH, please complete the CAQH ProView profile.

Who is the insurance provider for Blue Cross Blue Shield?

BCBS Companies STATE/TERRITORYAVAILABLE COMPANIES California Anthem Blue Cross Blue Shield of California Colorado Anthem Blue Cross and Blue Shield Colorado Connecticut Anthem Blue Cross and Blue Shield Connecticut Delaware Highmark Blue Cross Blue Shield Delaware48 more rows

How do I find my BCBS provider ID?

How do I find my Provider ID number or P#? Call Customer Care at 1-800-920-8889 and press #2 for Eligibility and Benefits. Refer to the notification letter sent from the Health Plan. If you cannot find your letter, call the Excellus BCBS Web Help Desk at 1-800-278-1247 .

What is my BCBS member ID number?

Your member number, also known as your identification number, is listed directly below your name. Youll need this information when receiving medical services at the doctor or pharmacy, or when calling customer service for assistance.

What is the provider record ID?

The Provider Record ID associates the providers rendering National Provider Identifier with their billing NPI and Tax Identification Number.

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