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: *


Your Name: *

Telephone Number: *

Your Email *

Fax Number: *