BlueCard Customer Service Contact Form

BlueCard Customer Service Contact Form

*Asterisks indicate required fields.

Please complete all fields of this form to ensure your request is processed quickly and accurately. Physicians, dentists, and other health care professionals and facilities may use this form to securely contact BlueCard^® Customer Service for questions or issues. Please submit one form per each patient, up to five dates of service.


Provider Information
Contact name*:
Contact phone*:
Your email address*:
Office/Clinic/Provider Name*:
Provider NPI or Tax ID Number(s)*:



Member Information
Member alpha prefix and ID number*:
Patient first and last names*:
Date(s) of service*:


Billed amount*:
Description of issue*:

Have you contacted us about this claim before?
	Yes	No
Customer Service response:
Customer Service Specialist:

You will receive an electronic response from Regence within 48 hours.