Fillable Provider Secured Access Application FAX COVER PAGE

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Provider Secured Access Application FAX COVER PAGE

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  • 41 check-boxes
  • 135 other fields

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Provider Secured Access Application
FAX COVER PAGE
Fax To:
From (office):
Date:
DEC 20
• 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**
Contact:
Provider Secured Access Application
Users cannot take their assigned IDs to other organizations.
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
Company issued email address to receive
assigned Provider Secured Services ID(s):
Section 3.
For offices that currently have access to e-referral and are requesting
access for additional users, provide the Set ID or a User ID from office
in Section 1.
Set/User ID
Section 4.
To view an example of a specific required code, place the mouse pointer in the center of the input field.
Assigned NPI Number(s)
Section 5.
BCN HMO and/or BCBSM Physicians
BCN Physician Organization
For individual providers, enter the Michigan state license number(s).
Enter the BCN IH Code(s)
BCBSM Physician Organization
Name/ Identifier(s)
To obtain secured access user IDs, complete page 2 of this form.
1
WF 15607 DEC 20
For Health e-Blue access, select the applicable network(s) below.
Please note - Requesting Health e-Blue will add additional processing time
Section 2.
Please add all NPIs from this existing User ID
for the features requested by new user(s) in
section 6.
ID must be from office listed in Section 1.
• NPIs listed below in Section 4 are for new access for Provider Secured Services and e-referral.
• All users receiving Claims Tracking & EFT access will automatically receive access to e-Referral.
• To add NPI(s) to an existing e-referral set ID - submit the e-referral Request for Group ID Changes.
(http://www.bcbsm.com/content/dam/public/Providers/Documents/help/e-referral-id-group-
changes.pdf)
• If additional space is needed, attach a separate listing of NPIs.
User ID
Check box if company issued
email address is unavailable.
Section 1.
I
hereby state the information provided on this application is correct and the provider/facility NPI(s) listed pertain to the facility only.
Signer's title
If the office does not have access to Provider Secured Services, submit a Use and Protection Agreement with this application.
Facility/Practice Name (Provider Name)
Section 6.
Check ONLY the requested features for each user, if no features are selected the user will receive eligibility only access.
Name
(Type in full legal name for each user)
MANDATORY
MANDATORY
Claims
Tracking
,
EFT
BCN PCP
Claims
Summary
Health
e-Blue
(HEB)
Assigned
Provider Secured Service ID
(If BCBSM has assigned the user an ID)
Example: John Doe
248-222-1111
X
X
X
Example: F######
Section 7. Mandatory
Authorization for use and access
I hereby state the information provided on this application is correct and the provider NPI(s) listed pertain to the provider only
Date
Type name of the authorized signer
Signer's title
If there are questions, call 1-877-258-3932. Hours of operation: Monday-Friday 8 am-8 pm
To the extent you are applying for access as a provider, all confidentiality provisions contained in your Participating Hospital Agreement/Hospital Affiliation Agreement are
applicable to every individual user granted secured access by this application.
I understand by signing this application I agree to only use and/or disclose BCN/BCBSM patient data for permissible treatment, payment and healthcare operation activities that
allow me to service and care for my Blues patients. I also further agree that I will only use and/or disclose Medicare Advantage data to service and care for my Medicare Advantage
patients.
By signing above, I represent that I am a Provider or the Authorized Representative and warrant that I have been granted full legal authority by corporate resolution, appropriate
delegated signature authority, or as permitted by a signature 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 above.
I addition, I understand that by signing above I have the company’s designated authority to request and maintain minimum necessary web access and am responsible for complying
with all terms and conditions contained within the Provider Secured Services Use and Protection Agreement.
https://www.bcbsm.com/content/dam/public/Providers/Documents/help/faqs/use-and-protection-agreement-professional-facility.pdf
Fax Application to 1-800-495-0812
© Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
2
WF 15607 DEC 20
Provider authorized signature
Handwritten signature only.
Provider Secured Access Application
Users cannot take the assigned IDs to other organizations.
Please complete electronically
1.
2.
3.
6.
4.
5.
7.
8.
9.
10.
If additional space is needed, attach and sign additional page 2 (sections 6 & 7).
X
User's Business
Telephone Number
e-referral
ADDENDUM "G"
Practice or Facility Name Contact Person
Street Address and Suite Number
Contact Person's Telephone and Extension
City
State Zip Code
Contact Person's company issued email address
Provider Group Name
Type 2 NPI(s)
Provider Enrollment and Change Self-Service Access Request
Name
(Type or Print Full Name of Each User)
Telephone Number
Provider Secured Services
ID
Provider Enrollment and
Change Self-Service
Basic Access
Provider Enrollment and
Change Self-Service
Full Access
John Doe
111-222-3333 F000000
Provider Enrollment and Change Self-Service Authorization
By signing below, I represent and warrant that I am an authorized group representative; I have been granted, by corporate resolution or otherwise, full legal authority
to enter into and bind my provider group to agreements. I understand, acknowledge, and attest that the user(s) listed on this Addendum have the authority to
perform all transactions associated with the requested features on behalf of the Provider Group, Individual Provider, and/or Provider Organization, and that I (as the
Provider Group, Individual Provider, and/or Provider Organization) am responsible for all actions undertaken by the listed individuals.
Note: This is an Addendum to the Provider Secured Services Use and Protection Agreement and does not alter the terms set forth therein.
Name of Authorized Group Representative Title of Authorized Group Representative
Signature of Authorized Group Representative
Handwritten signature only
Date
Please complete electronically
Authorization for Provider Enrollment and Change Self-Service
WF 16643 DEC 20
1
Section 1.
Section 3.
Provider Enrollment and Change Self-Service Basic Access: Allows users to maintain group demographics and composition only.
Provider Enrollment and Change Self-Service Full Access: Allows users to maintain group demographics and composition plus the ability to enroll and add new
practitioners to the group.
Each transaction creates an audit trail and provides user controlled demographic changes with the ability to check the status of your change requests online anytime
with a few mouse clicks.
Section 5.
Fax to 800-495-0812 or for questions call 877-258-3932
Section 2.
Select one role
Remove Provider Enrollment and Change Self-Service Access
Section 4.
John Doe
111-222-3333
F000000
John Doe
111-222-3333
F000000
Name
(Type or
Print Full Name of Each User)
Telephone Number
Provider Secured
Services
ID
Name
(Type o
r Print Full Name of Each User)
Telephone Number
Provider Secured
Services
ID
Type 2 NPI(s) to remove
© 1996-2015 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
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Provider Secured Access Application FAX COVER PAGE

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Completed 1 February 2021

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