Fillable Instructions for fax cover sheet (Blue Cross Blue Shield of Michigan)

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Instructions for fax cover sheet (Blue Cross Blue Shield of Michigan)

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WF 13764 OCT 18
Page 1 of 4
Questions? Call 1-800-822-2761
1. Fax cover sheet must be the first page of your form submission.
2. Fax the registration form and attachments (i.e., signature documents) to
1-866-900-0250. Be sure to fax the registration information separately for
each provider. (For example: If you register two or more providers, you must
send a fax for each provider. They cannot be bundled into one fax
transmission.)
Instructions for fax cover sheet
We cannot accept handwritten forms. To ensure forms are processed timely,
please adhere to the following instructions:
1. Do not hand write anywhere on the form, otherwise processing will be delayed.
2. Enter all information online; press the tab key after each entry to move from eld
to eld.
§ For individual practitioners and Groups
§ From (Insert name of contact person)
§ Date (MM/DD/YYYY)
§ Type 1 NPI National Provider Identifier
§ State license number
§ Tax identification number
Instructions for Provider Self-Service
Provider groups can update the afliated practitioner information on Provider Self
Service. The self-service process in faster and easier than paper submission. Please
refer to the manual or CBT for updating instructions.
Instructions for form submission
13764
Tax Identication Number:
NPI 2:
Form Number:
BCBSM Network Panel Change Form
Date:
From:
Fax To: 866-900-0250 Provider Enrollment
IMPORTANT: Attach this page to the top of your document to
avoid processing delays.
FAX COVER SHEET
FOR DOCUMENTS
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
WF 13764 OCT 18
Page 2 of 4
*Call your Provider Consultant to update any BCN Network panel.
WF 13764 OCT 18
National provider identier
Tax Identication Number
Page 3 of 4
Please complete this form if you want to update one or more physicians' “Accepting Network Panel”
status information. This information will be added to the BCBSM/BCN online directory and will
provide details for your patient demographics profile.
Please check all network(s) that apply to the change/update you are requesting:
Medicare Advantage
SM
PPO Blue Preferred Plus
PPO TRUST
Open Practice Status
Accept new patients into practice:
Yes No
Limited
Limited Status (Only use if you selected “Limited” above):
Current patients only
NewbornRUIamilyRIFurrent patients
Current patients only
Limitations
Gender limitations:
Male Female
All
Age limitations:
Panel limit: (number of patients)
Lowest Age:
Years Months
Highest Age:
Years Months
Apply to 'all' practitioner affiliations in this group? Yes No
If no, list individual practitioner's name, practitioner NPI and indicate 'All Locations' or 'Primary
Location only'.
All Locations Primary Location Only
Practitioner Name Practitioner NPI Location/Address
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
Practitioner afliations in this group continued on next page
Apply to all Networks listed above
BCBSM Network Panel Change Form
Groups
I certify that the information contained in this application is true and complete and I am authorized to
make these changes on behalf of my group. I will notify Blue Cross and Blue Shield of Michigan and
Blue Care Network immediately in writing of changes affecting this data.
Application signature
*Authorization signature
*Date
Print or type name
*denotes a required eld
National provider identier
Tax Identication Number
All Locations Primary Location Only
Practitioner Name Practitioner NPI Location/Address
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
All Locations Primary Location Only
WF 13764 OCT 18
Page 4 of 4
BCBSM Network Panel Change Form
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Instructions for fax cover sheet (Blue Cross Blue Shield of Michigan)

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Completed 29 March 2022

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