PA Resources Portlet













PA Dynamic Rendering


Provider Maintenance

For enrolled provider that have not been inactive or cancelled from participating status for six months or more.

Blue Cross and Blue Shield of Alabama enrolls and credentials all individual providers as well as ancillary and facility providers. Here are the forms/documents to add locations and make changes to information and other requests.

An application, from the Enrollment section, is needed for any provider in the following situations:

  • New providers practicing within the State of Alabama and that need to be enrolled for claims processing
  • Inactive or canceled providers (six months or more) that no longer have network status (use the UPA from the Enrollment section)
  • New providers joining an existing tax identification number

Note: Providers outside of Alabama must be participating with their local Blue Plan for consideration for participation with Blue Cross and Blue Shield of Alabama.

Existing providers who are: 

  • Adding a new location, or
  • Joining an existing tax identification number, or
  • Changing the tax identification number for an existing practice.

Follow the steps below:

Step 1 - Required Documents for All Providers/Specialties

There are several required documents that you must submit for enrollment. Print this Practitioner Checklist or Facility/Business Checklist to track your progress throughout enrollment and ensure that all necessary documents/forms are submitted. Some of the required forms are provided in step 2.

Step 2 - Provider Enrollment Application/Supporting Documents

Click on the appropriate specialty from the list below to view and print the application and list of supporting documents necessary for enrollment. By utilizing the proper application and returning the correct supporting documents, you can significantly speed up the enrollment process. Submit all current supporting documentation in a legible format.

Applications/Supporting Documentation Requirements

Step 3 - Express Your Network Interest

Complete the Practitioner Network Interest Form or the Facility Business Network Interest Form that is included with the application for your specialty. It is required for all new applications and expresses your interest in network participation. After the enrollment process is complete, a provider will be reviewed and may be invited to participate in a network if all criteria are met.


  • Enrollment is not the same as joining a Blue Cross Provider Network. 
  • Enrollment and expressed interest in network participation are not a guarantee of acceptance as a participant in a network.

Additional Documents

Application Document Package - Includes all forms that are required for new and existing providers.

Practitioner Application Package


Facility Business Application Package

Interested in Joining a Network

  • Provider who is currently enrolled with Blue Cross and Blue Shield and is interested in participating in a network
  • Provider on initial application that indicated they were not interested in a network, but wants to reconsider
  • Providers going through recredentialing still interested in being in our networks

Practitioner Network Interest Form


Facility Business Network Interest Form

Update Office Address

Provider Change Notification


Update Payee/Remit Address*
*Requires authorized, original signature of CEO, CFO, President, Tax Manager or Provider if sole owner.

Update Tax Address*
*Requires authorized, original signature of CEO, CFO, President, Tax Manager or Provider if sole owner.

Update Telephone Numbers

Update Provider or Office Email

Changes in Organizational/Payee NPI*
*Requires authorized, original signature of CEO, CFO, President, Tax Manager or Provider if sole owner.

NPI Change Notification

Authorization to Contact facilities for verification

Hospital Data Form

Substitute W9 Documentation

Request For Taxpayer Identification Number

Set up Direct Deposit of Provider Payments

Direct Deposit/EFT Registration

PRP New Physician Form

Add a new physician to the the Preferred Radiology Network

Preferred Radiology Program New Physician Form


Practitioner Rights