Fillable PROVIDER UPDATE FORM Use this form to tell

Fill Online, Printable, Fillable, Blank PROVIDER UPDATE FORM Use this form to tell Form

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

PROVIDER UPDATE FORM Use this form to tell

On average this form takes 15 minutes to complete

The PROVIDER UPDATE FORM Use this form to tell form is 2 pages long and contains:

  • 0 signatures
  • 10 check-boxes
  • 57 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
PROVIDER UPDATE FORM
021126 (06-24-2020) Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association
1 of 2
Use this form to tell us about any new information or changes to your current practice or payment structure.
You can email this completed form to Provider.RelationsWest@premera.com or fax it to 425-918-4937.
If you have any questions, call Provider Relations at 877-342-5258, option 4.
Fields marked with an asterisk * are required for all changes/updates.
*PROVIDER INFORMATION:
*Provider Office Contact:
*Phone:
*Email:
*Tax ID:
*Type of change/update:
Address (any
type)
New provider/clinic
name
Phone (any
type)
Add new
location
Specialty
Tax ID (W-9
required)
*Effective date of change:
OLD INFORMATION: Only complete the fields below where the current information we have on file is changing.
Old clinic name:
Old provider name:
NPI:
Physical location address:
Street address:
Suite number:
City: State: ZIP:
Phone number: Fax number:
Specialty:
Remit/payable to address:
Street address:
Suite number:
City: State: ZIP:
Mailing address:
Street address:
Suite number:
City: State: ZIP:
2 of 2
Credentialing
address:
Street address:
Suite number:
City: State: ZIP:
Phone number: Fax number:
NEW IN
FORMATION: Complete the fields below with your updated information.
New clinic name:
New provider name:
Tax ID:
NPI:
New demographics apply to the following types of addresses: (check each one that applies).
Physical Address Mailing Remit/Payable Credentialing
Street address:
Suite number:
City: State: ZIP:
Phone number: Fax number:
Specialty:
Ot
her address (please explain in comments):
Street address:
Suite number:
City: State: ZIP:
Phone number: Fax number:
Comments:
To get all the latest Premera news, sign up for email updates today!
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

PROVIDER UPDATE FORM Use this form to tell

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 22 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document