Provider Consultant Contact Form

Please note: This form is to be used by physicians, other health care professionals and facilities to contact their assigned provider relations consultant.

Please complete a Provider Information Update Form when:

  • A provider leaves or joins your clinic or practice
  • You have a change to your:
    • Organization's address
    • Phone number
    • Tax identification number
    • National Provider Identifier number

The results of this form are encrypted and sent to our secure server for your privacy. Your form will be sent directly to your provider consultant.

*Asterisks indicate required fields.

I would like information on the following:
Reimbursement Policy
Our issue/problem is:
Medical Policy
 
Our issue/problem is:
General billing and coding methods relating to:
 
(please describe)
I would like to request a new provider orientation
Other request (please describe)
I would like to request free training in my office. Please indicate the training you would like to receive below.
 
The BlueCard® Program
 
Provider Center
 
TriWest
 
Other (please describe)
Other request (please describe)
       
*How would you prefer to be contacted?
Phone    
Email    
       
Your details:
*
 Name:
*
 Email:
*
 Phone number:
*
 Office/Practice name:
*
 Office/Practice address:
*
 Tax ID: