Fillable Physician & Group - Request to Participate

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Physician & Group - Request to Participate

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The Physician & Group - Request to Participate form is 2 pages long and contains:

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  • 11 check-boxes
  • 49 other fields

Country of origin: OTHERS
File type: PDF

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900-2623-0512
Physician & Group - Request to Participate
If you need assistance completing this form, please contact the Provider Contact Center at 1-800-727-2227. Say more choices, option 5, and
then option 2.
Request Type
A Physician Billing Authorization form is required for group requests. Click here
Please indicate the Blue Cross Blue Shield of Florida Provider Network(s) you are interested in participating with:
PPO
Blue Select
Traditional
ADV 65
HMO
Blue Options
Medicare
PPO
Medicare HMO
Click here to check what Networks are currently open.
Provider Numbers (* Indicates a required field)
*Florida Blue Provider Number
Medicare UPIN
Please complete a registration form, if you do not have a Florida Blue provider number. Click here
National Provider Identifier (NPI)
Billing TIN/EIN or
SSN
Medicaid Number
Contact information
Provider Contact Information
Phone Number
Fax Number
Email Address
Credentialing Contact Information
Contact Name
Email Address
Phone Number
Fax Number
Provider Demographics
Provider's Full Legal Name
Title
Provider's Preferred Name
(To display in directory)
Office Contact
(If different from Credentialing Contact)
Main Service Location
(No PO Box)
Street Address County
City State Zip Code
Billing Address
Same as service location
Mailing Address
Same as service location
Same as billing location
Street Address
City State Zip Code
Group Affiliations
Are you affiliated with a group?
Group’s Florida Blue Number
Group’s Name
Group’s Service Address
Contracting Specifics
Practicing Specialty
Board Certified?
Yes No
If yes, what specialties are you board certified in?
Street Address County
City State Zip Code
Yes No
Yes No
Fax to: 904-301-1884
900-2623-0512
Are Advanced Imaging Services provided at your service location?
(If yes,
accreditation by The Joint Commission,
American College of Radiology (ACR) or Intersocietal Accreditation
Commission (IAC)
documentation must be provided.)
Yes No
List all hospitals you have admitting privileges to
(if applicable)
Do you carry Professional Liability Insurance Coverage?
Yes No
Credentialing Specifics
If you
currently
use CAQH for your
application
data, please
provide
your CAQH
Number
Note: Your
information
on
CAQH
must be completed in its
entirety,
all
documentation
uploaded and
information
currently
attested to in order for us
to
proceed with this request. Failure
to
do so will result in request being closed.
Florida Blue has an
agreement
with Medversant to
perform
the data
collection
and
validation
of the required
credentialing
elements.
You may be
contacted
by Medversant on behalf of Blue Cross Blue Shield of Florida to
obtain
any
information
that is
missing or
incomplete
on your
application
Additional Information
Please
provide a brief description of
pertinent
details of your practice you deem applicable to complete this form such as disassociation
from a
group, etc.
Comments:
.
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Physician & Group - Request to Participate

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Completed 7 December 2021

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