ProviderAccess New User Registration Request

Use this form to request a ProviderAccess sign-in ID and password. Required fields are denoted with an asterisk (*).

Section I: Contact Information

Contact Name:*

Contact Telephone Number:*

( ) Ext:

Contact Fax Number:

( )

Address:*

City:*

State:*

Zip Code:*

Provider Email Address:

Do you currently utilize a software vendor to file your claims to Blue Cross and Blue Shield of Alabama?*

No Yes

If Yes, please enter the name of the software vendor:

Section II: Select Options

Web page transactions are for non-Medicare data only. Please check the option(s) that you are interested in.

Professional Providers:

	WebClaims (Direct keying of claims using a Web application)
	Claims Batch File (NSF) Submission (Do not select if using WebClaims)
	Audit Trails
	Remittances
	Patient Accounts (Includes Eligibility and Benefits, Claim Status, Payment History, Fee Schedule)

Institutional Providers:

Remittances

Section III: Provider Information

Enter the Provider Number, Provider Name, and Tax ID Number for each provider who is registering. All fields are required.

By selecting Submit, I agree that I am authorized to request a ProviderAccess sign-in and password for the above provider number(s).

Requestor Name:*