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 10579 SEP 18
Page 1 of 8
Questions? Call 1-800-822-2761
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.)
1.
Fax cover sheet must be the first page of your form submission.
Instructions for document submission
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 2 NPI National Provider Identifier
Tax identification number
.
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 2 NPI National Provider Identifier
Tax identification number
Instructions for fax cover sheet
We cannot accept handwritten forms. Do not hand write anywhere on
the form, otherwise processing will be delayed.
For individual practitioners
.
.
.
.
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 1 NPI National Provider Identifier
State license number
When adding an individual to an existing group, be sure
to fax a group change form
.
For allied providers
.
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For professional group practices and facilities
.
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10579
State License Number:
Form Number:
PRACTITIONER CHANGE FORM
Mail to:
Provider Enrollment - C334
Blue Cross Blue Shield of Michigan
P.O. Box 217
South ield, MI 48034
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 10579
SEP 18
Page 2 of 8
Type 1 NPI:
Type 1 National provider identifier
Page 3 of 8
State license number
WF 10579 SEP 18
PRACTITIONER CHANGE FORM
If you are a MD, DO, DC, DPM, DMD/DDS (Board certified oral surgeon only), independent physical therapist,
independent occupational therapist or independent speech language pathologist, use this form to:
Change Medicare/PTAN number, EIN/Tax ID number and/or tax name – Section 2
Request additional networks – Section 3
Request to terminate networks – Section 4
Change BCBSM participation status – Section 5
BCN PCP changes – Section 6
Change remit/mailing/medical records address – Section 7
Add/end practice locations – Section 9
End practitioner's relationship with a group – Section 10
Change Type 1 NPI – Section 11
Contact Information – Section 12
Application Signature – Section 13
Provider Race/Ethnicity Information – Section 1
.
.
.
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The following fields must be changed through the CAQH at
First name
Middle name
Last name
Suffix
Date of birth
SSN
Primary address
Specialty/Board certification
.
.
.
.
.
.
.
.
Section 1: Demographic Data
Race/Ethnicity
White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Chinese/Chinese-American
Filipino
Japanese/Japanese-American
Korean
Vietnamese
Section 2: Change EIN/Tax ID number and/or tax name
EIN/Tax ID number
EIN/Tax ID name as indicated on internal
revenue service document
Tax exempt: Effective date:Yes No
Note: If your payment and remittance address changes as a result of your change in EIN Tax ID
Native Hawaiian or other Pacific Islander
Mexican/Mexican-American
Hispanic/Latin American
Arab
Other Race
Assyrian/Chaldean
Other Asian
Multiracial
Not Disclosed
You must also update your payment and remittance address on CAQH
Include IRS Form 147c or an IRS Tax Deposit Coupon.
.
.
Change Services – Section 8
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.
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.
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If you would like to bill with your Type 2 NPI representing your incorporated individual business, you must
also complete a New Group Enrollment form to register this entity as a group.
Medicare/PTAN number
https://proview.caqh.org/PO
Page 4 of 8
Type 1 National provider identifier
State license number
PRACTITIONER CHANGE FORM
Section 3: Request additional networks
If you are applying for a managed care network, you must complete your Council for Affordable Quality
Healthcare (CAQH) application within 14 calendar days. If you have already completed CAQH, your
attestation must be up to date. If your CAQH application is not complete or if your attestation is expired after
14 calendar days, your request will be closed and you will need to reapply.
®
You will be notified of your status and the e fective dates of affiliation in BCBSM and BCN managed care
networks after credentialing for the networks is completed and BCBSM and BCN has counter-signed your
affiliation agreements. Important: Along with this application, it is necessary to complete and submit
the signature document appropriate for your provider type. For each network you wish to participate
in, be sure to place a check mark by the appropriate affiliation agreement, sign the signature
document, and submit it along with this form.
BCBSM and BCN do not permit retroactive effective dates in managed care networks.
Select networks you are applying to:
Provider Type
Eligible Networks for Provider Type
Doctor of Medicine
Doctor of Osteopathy
Chiropractor
Podiatrist
Oral Surgeon
Independent Physical Therapist
Independent Occupational Therapist
Independent Speech Language Pathologist
Section 4: Termination of networks
Note: If you are terminating all networks, please complete the Practitioner Termination Form.
Requested termination date - The actual date of your termination will be determined based on the
provisions in the applicable participation agreements.
BCBSM Networks Requested termination date
Date:
Hearing
TRUST PPO
Date:
Date:
BCN Commercial
Date:
Date:
BCN Advantage HMO
Blue Preferred Plus
BCN Networks
Requested termination date
SM
Other Requested termination date
Date:
BCN Commercial
BCN Advantage
SM
HMO
TRUST PPO
If you are a specialist billing with a Type 2 NPI, BCN contracts with the Group Practice. Please follow
instructions on the website for Professional Group Enrollment.
Vision/Hearing (if applicable)
TRUST PPO
Medicare Supplemental
WF 10579 SEP 18
Traditional-Participating
Traditional-Non Participating
Blue Preferred Plus
Traditional-Participating
Traditional-Nonparticipating
Blue Preferred Plus
Medicare Advantage
SM
PPO
Date:
Medicare Advantage
SM
PPO
Medicare Advantage
SM
PPO
Page 5 of 8
Type 1 National provider identifier
State license number
WF 10579 SEP 18
PRACTITIONER CHANGE FORM
Section 5: Change BCBSM participation status
The actual date of your participation status will be determined based on the provisions in the applicable
participation agreement.
BCBSM Networks
Requested participation change
Traditional
Vision
Non-participating to Participating (include Individual Signature document)
Participating to Non-Participating (effective 60 days upon receipt of request)
Non-participating to Participating (include Individual Signature document)
Participating to Non-Participating (effective 60 days upon receipt of request)
Section 6: BCN PCP changes
Are you applying to BCN to be a primary care physician?
Section 7: Change remit/mailing/medical records address
Are you currently a PCP requesting to change your
medical care group endorsement?
Yes No
Yes No
If yes to either of the above questions, please provide the name of the MCG you wish to join.
MCG name:
MCG number:
Are you currently a PCP requesting to be a specialist?
Yes No
If you are an endorsed specialist, please contact your MCG who will submit your acknowledgment
signature document to BCN on your behalf. For more MCG information go to:
http://www.bcbsm.com/pdf/bcn_par_mcg_endorsement.pdf
Payment/Remit address
Effective date
Street address
City
State
Zip Code
Mailing Address
Effective date
Street address
City
State
Zip Code
BCN Commercial
If yes, select network(s) you are appling to:
BCN Advantage
SM
HMO
Page 6 of 8
Type 1 National provider identifier
PRACTITIONER CHANGE FORM
State license number
WF 10579 SEP 18
All Practitioner Services:
Add Remove
Occupational Therapist, Physical Therapist, Speech Language Pathologist Services:
Autism services
Medical Records Request (MRR)
Street Address
City State Zip code
Contact Name - First Middle Last
Telephone Fax Email
Section 7: Change remit/mailing/medical records address - continued
Section 9: Add/end Practice Locations
Note: Address details only required if adding a practice location. This must be an address where health care
services are rendered and may be published in BCBSM and BCN provider directories.
#1 Address details:
Add this location
End this location
Effective Date:
Effective Date:
Street address
City
State
Zip Code
Telephone number
Fax number
Ofce hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open time
Close time
Section 8: Change Services
Add Remove
Telehealth Services:
Add Remove
Add Remove
Telemedicine Offered-audio and visual
Telemedicine Originating Site
Real-time on-line visit/e-visit
Add Remove
Add Remove
Lactation counseling
In-home visits
If adding, please indicate below if you practice exclusively in the home setting or
if you also provide care in an office setting: In home only In home and office
Type 1 National provider identifier
State license number
PRACTITIONER CHANGE FORM

Page 7 of 8
WF 10579 SEP 18
Section 9: Add/end practice locations - continued
#2 Address details:
Add this location
End this location
Effective Date:
Effective Date:
Street address
City
State
Zip Code
Telephone number
Fax number
Ofce hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open time
Close time
If you have additional practice locations that you want to add/end, please list and attach separately.
Group name Type 2 NPI
Effective date of Termination
Section 10: End practitioner's relationship with a group
Identify group(s) you are no longer affiliated with as a practitioner.
Check here if physicians were acting as a BCN PCP
Primary Location
Do you need to change your primary location? Yes No
If yes, the change must be made through CAQH at
Additional Location(s)
Do you need to add additional location(s)? Yes No
If yes, include address details when adding a practice location. This must be an address where health care services
are rendered and may be published in the BCBSM and BCN provider directories.
If no, and you are only ending a location (other than the primary location), address details are not required.
https://proview.caqh.org/PO
Page 8 of 8
Type 1 National provider identifier
State license number
WF 10579 SEP 18
PRACTITIONER CHANGE FORM
Section 13: Application signature
*
denotes a required field
I certify that the information contained in this application is true and complete. I will notify Blue Cross and
Blue Shield of Michigan and Blue Care Network immediately in writing of changes affecting this data. If I am
a practitioner in training, I will not report services that are related to my training program and rendered at the
address from which I am training. Should I re-enter training, I will notify BCBSM and BCN.
*Practitioner signature/Title
*Date
*Print or type name
For providers applying to be Traditional non-participating providers, the authorized signer agrees on behalf
of itself and the provider on whose behalf the authorized signer is acting, to adhere to BCBSM’s Billing
Guidelines for Non-Participating Providers. These Guidelines include, without limitation, the requirement
to permit BCBSM or its designee physical access to the provider’s premises to review and/or copy for any
permissible purpose any and all medical and billing records submitted by the provider or its billing agent;
and the requirement that the provider accept BCBSM’s payment as payment in full for services rendered
to a BCBSM member when the provider has indicated that it will accept assignment of payment on the
member’s behalf, will participate with BCBSM on a particular claim, or has otherwise indicated that he/she
wishes to receive payment directly from BCBSM and, with the exception of any applicable deductibles,
co-payments, or co-insurance amount, not balance bill the member for the difference between BCBSM’s
payment and the provider’s charged amount.
Section 12: Contact information
*
denotes a required field
Contact information
Please provide the name and contact information of a person who can answer questions about information in
this application.
*First name *Last name
*Telephone number
Fax number
Work email address
Preferred method of contact?
E-mail US mail
Extension
Previous Type 1 NPI New Type 1 NPI
Reason for change
Sec tion 11: Change Type 1 National provider identification
Click here for explanation
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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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