REQUEST FOR BENEFITS AND ELIGIBILITY

 

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.

* Required Fields

Name of Provider: *              

Are you a Blue Shield Provider: *  Yes   No

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 E-Mail Address: *   Fax Number: *