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Before you start

Use this guide when AZ Blue is a required Local / Host Plan for your practice or claim-service location. Its non-contracted provider form creates or updates the information needed for claims processing; it is not a network-contract application. If registration is incomplete, claims can be delayed. Not sure which plan applies? First identify your required Local / Host Plan. Registration is separate from joining a network.

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Complete the professional-provider form

1

Download the current form

Open AZ Blue’s provider forms and select Non-Contracted Provider Information. Download the form before filling it out.
2

Identify the clinician and practice

For an individual professional, complete sections 1 and 3, plus the contact-person fields. Section 1 includes the clinician’s individual NPI and the applicable group name, DBA, and organization NPI.A group of therapists is not a facility simply because it has several clinicians. Section 2 is for facilities.
3

Add billing and location information

In Section 3, enter the practice’s TIN and the date the clinician began billing under it. Complete the physical service, billing, mailing, and medical-record addresses as requested. Follow the form’s instructions when an address is the same as another.
4

Review, sign, and send

Have the authorized person review and electronically sign the form, save it, and send it with applicable supporting documents to ProvNet@azblue.com. Keep a copy and ask AZ Blue to confirm when the record is active.

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Groups and existing records

Your practice coordinates the clinicians’ records under its billing information. If you need to add several clinicians or update an existing record, ask AZ Blue which forms or affiliation steps it needs. Do not assume the form supports a bulk roster. For form questions, call 602-864-4231 or 800-232-2345, as listed on the current form.

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What happens next

Once each required plan confirms registration and the required clinician associations are active, notify Thrizer support and review what happens next. The payer controls registration and claim decisions. Registration does not guarantee reimbursement or recognition of every clinician category. For associate, pre-licensed, or supervised clinicians, ask the payer about recognition and review Thrizer’s supported claim structure.