CoverKids

Provider Disclosure Forms

The Provider Disclosure form from this site should be completed and returned to:

BlueCross BlueShield of Tennessee (BCBST)
One Cameron Hill Circle, Suite 0007
Chattanooga, TN 37402
Fax: (423) 535-3066
Fax: (423) 535-5808

1. Disclosure Form for a Provider Person (click here and the document will appear in PDF)
2. Disclosure Form for Provider Entities (click here and the document will appear in PDF)

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