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