If you are a provider and need information as to the eligibility and benefits for a member or dependent, please complete this form click on the send button. The requested information will be sent to you via secure email.
Name of Provider: *
Are you a Blue Shield Provider: * YesNo
Provider Tax ID Number: *
Specify Office Specialty: *
Name of Patient: *
Patient DOB: *
Member ID Number * (See membership card):
Reason for Visit: *
Questions:
Your Name: *
Telephone Number: *
Your Email *
Fax Number: *
3500 W. Orangewood Ave. Orange, CA 92868
Phone: 714 / 917-6100
Fax: 714 / 917-6065