Fillable Authorization To Modify FAX COVER PAGE (Blue Cross Blue Shield of Michigan)

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Authorization To Modify FAX COVER PAGE (Blue Cross Blue Shield of Michigan)

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Authorization To Modify
FAX COVER PAGE
WF 15607 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**
Fax To:
From (office):
Contact:
Date:
I hereby authorize the User(s) of the above Provider Secured Service Logon ID(s), in the office of
(Professional/Facility Provider Name), to access any and all information provided via Provider Secured Services which includes, but is not limited to, detailed
claim information and payment information either now or in the future for both
my individual and/or group provider codes.
Authorization
By signing below, I represent and warrant that I have been granted full legal authority, by corporate resolution,
appropriate delegated signature authority,
or as permitted by a signature authorizing policy, to enter into and bind the provider and / or
provider group to contracts and agreements and intending to
be legally bound have executed this agreement on the date below.
If NPI(s) should be added, list NPI(s) and User ID(s) below.
NPI Numbers
10-digit NPI Number
10-digit NPI Number
10-digit NPI Number
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.
NPI Numbers
NPI Numbers
Remove from the below User IDs:
ID is either a P###### or F######
10-digit NPI Number
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
WF 4928 SEP 19
© 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.
AUTHORIZATION TO MODIFY BCBSM AND OR BCN PROVIDER CODES
ON PROVIDER SECURED SERVICE ID
Please Complete Electronically
Facility/Office Practice Name (where users are located)
Provider Specialty
Street Address and Suite Number (address where users are located)
Contact Person
City State Zip Code
Tax ID
Contact Person's Telephone and Extension
Contact Person's company issued email address
10-digit NPI Number
10-digit NPI Number
10-digit NPI Number
10-digit NPI Number
REMOVE NPI(s)
ADD NPI(s)
10-digit NPI Number 10-digit NPI Number
User ID
User ID
User ID
User ID
User ID
User ID
User ID
User ID
To duplicate NPI access from an active User ID, enter the ID here
User ID
NPI Numbers
User ID
User ID
User ID
User ID
User ID
User ID
User ID
User ID
Section 1.
Section 2.
Section 3.
Section 4.
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Authorization To Modify FAX COVER PAGE (Blue Cross Blue Shield of Michigan)

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Completed 10 February 2021

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