Fillable Addendum "B" FAX COVER PAGE (Blue Cross Blue Shield of Michigan)

Fill Online, Printable, Fillable, Blank Addendum "B" FAX COVER PAGE (Blue Cross Blue Shield of Michigan) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Addendum "B" FAX COVER PAGE (Blue Cross Blue Shield of Michigan)

On average this form takes 12 minutes to complete

The Addendum "B" FAX COVER PAGE (Blue Cross Blue Shield of Michigan) form is 2 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of Michigan forms online.

BROWSE BLUE CROSS BLUE SHIELD OF MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Addendum "B"
FAX COVER PAGE
Fax To:
From (office):
Date:
SEP 19
• We cannot accept handwritten forms.
• Do not hand write anywhere on the forms(except for the signature), otherwise
processing will be delayed.
• To ensure forms are processed timely, please adhere to the following instructions :
o Enter all information online(Google Chrome or Internet Explorer work best).
o Press the tab key after each entry to move from field to field.
We’re always looking for ways to protect our member’s information and keep your account
secure. That’s why we’d like to connect your online account to an email address that’s related
to your business rather than a public email provider such as Hotmail, Gmail or Yahoo.
If you have a company email address, please include it on your request for access or changes to
your Provider Secured Services account at bcbsm.com. If you’re not sure whether a company
email address is available to you, check with your website administrator. Most websites offer a
domain email free with your account. If you’re a smaller practice that doesn’t host a website,
we’ll accept your request with the email you use to conduct your business.
PLEASE NOTE!!
**ATTENTION**
Contact:
Section 1.
If NPI(s) should be added, list NPI(s) and User ID(s) below.
Provider or Group Name
NPI Number
Add to the below User IDs:
ID is either a P###### or F######
10-digit NPI Number
10-digit NPI Number
10-digit NPI Number
If NPI(s) should be removed, list NPI(s) and User ID(s) below.
Provider or Group Name
NPI
Number
Remove from the below User IDs:
ID is either a P###### or F######
10-digit NPI Number
Date
Type Name of the Authorized Signer
Title of Authorized Individual
Signature of Provider/Facility Authorized Individual
Handwritten Signature Only
For questions call 1-877-258-3932 Send Fax to 1-800-495-0812
WF16471 AUG 20
© Blue Cross Blue Shield of Michigan and Blue Care Network are a nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Billing Service/Service Bureau, TPA Name (where users are located)
Billing Service/Service Bureau, TPA Tax ID
Street Address and Suite Number (address where users are located)
Billing Service/Service Bureau, TPA Contact Person
City State Zip Code
Contact Person's Telephone
Contact Person's company issued email address
Extension
10-digit NPI Number
10-digit NPI Number
REMOVE NPI(s)
ADD NPI(s)
10-digit NPI Number
Tax ID
User ID
Tax ID
User ID
Tax ID
User ID
Tax ID
User ID
ADDENDUM "B" Authorization
Authorization for Representative Access to Provider Secured Services/e-referral Form
Please complete electronically
Authorization for Provider Secured Services and/or e-referral (To be completed by the Provider or the Authorized Representative for the provider/
facility).
This Authorization for Representative Access Form permits you to authorize a billing service or TPA to have access to designated information for your
indi
vidual and/or group provider NPI(s) for both Provider Secured Services and/or e-referral access.
The Billing Service, Service Bureau or TPA listed above, is authorized to access the information provided via Provider Secured Services and/or e-referral
either now or in the future, for both individual and/or group NPI(s) which is the minimum information necessary for performing their job function. If
the Authorized Representative's duties involve the use or disclosure of Protected Health Information (PHI), then the Health Insurance Portability and
Accountability Act of 1996, as amended (HIPAA), and stricter state and federal laws, as applicable, require the PHI be protected from inappropriate
uses or disclosures.
By signing below, I represent I am a Provider or the Authorized Representative for the Provider/facility and warrant I have been granted full legal
authority by corporate resolution to update BCBSM enrolled NPI(s) to Provider Secured Services login ID's and/or e-referral on the date set forth
below. If the signatory contractually represents multiple providers in the business of health insurance billing/inquiry, they must include a printout of all
such codes with this Addendum.
In addition, I understand that by signing below I have the company’s designated authority to request and maintain minimum necessary web access and
am responsible for complying with all terms and conditions contained within the Billing Service/Third Party Management Use and Protection
Agreement.
https://www.bcbsm.com/content/dam/public/Providers/Documents/help/billing-service-use-and-protection-agreement.pdf
Set ID
Section 2.
Section 3.
Section 4.
User ID
Remove NPI from all IDs
Tax ID
User ID
User ID
Check to also receive e-referral access
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Addendum B FAX COVER PAGE (Blue Cross Blue Shield of Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document