BlueChoice Select Application Request

An asterisk (*) indicates a required field.

*Provider Name:
National Provider Identifier (Type 1)
- if applicable:
Group Name:
National Provider Identifier (Type 2)
- if applicable:
*Tax ID Number:
Primary Hospital Affiliation
*Contact Name:
*Contact E-mail Address:
*Practice Address:
*City:
*County:
*State:
Note: You must practice in IL or Lake County, IN in order to apply.
*Zip Code:
Type of Degree:
*Phone Number:
(Include Area Code)
- -
*Specialty:
*Professional License Number:
*State of Issue:
Additional Comments: