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50 11/2005
FEE SCHEDULE REQUEST FORM
Please complete the following to submit your request and provide the necessary address or fax
information needed to return the fee schedule request information:
*Provider or Group Name:
Contact Name:
*Tax I.D.:
*Email Address:
*Street Address:
*Fax Number:
*Denotes that this is a required field
Please send requests via email, fax or phone call:
Email
• IPSUNorth@bcbsga.com
- Participating providers practicing in the Atlanta metro
area and all areas north of Atlanta.
• IPSUSouth@bcbsga.com
- Participating providers practicing in all areas south of
Atlanta.
Fax
• Please fax request form to 404-467-2631
Phone
• 404-231-0428 – For all participating providers in the Atlanta metro area
• 888-706-3475 – For all participating providers in North Georgia
• 800-428-4446 – For all participating providers in South Georgia