Fillable V510 Group Enrollment Application

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V510 Group Enrollment Application

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The V510 Group Enrollment Application form is 2 pages long and contains:

  • 1 signature
  • 22 check-boxes
  • 99 other fields

Country of origin: OTHERS
File type: PDF

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Blue Cross and Blue Shield of North Carolina
Group Enrollment Application
Please print in blue or black ink or type.
Please Check One:
Non Participating Enrollment Request
Participating Contract Request
Group Name: Specialty:
Tax Id (IRS#): National Provider Identifier (NPI):
*(Attach W9) Type II (Billing NPI)
Taxonomy Code/Description: Medicare Provider#:
(Required for Blue Medicare)
CLIA# (if applicable):
(REQUIRED:Please attach most recent copy)
Office Location Information: (Service location) Please list additional service locations on Page 2
Physical Address:
Street Suite, Apt, Unit, Floor, etc
City State Zip
County
Phone:
Appointment/Patient Phone Number Fax Number
Practice Email Address:
Billing Address
City State
Zip
Have you ever had a BCBSNC provider number (PPN)? Yes No If yes, please list the number(s)
Indicate the place(s) of service where services will be rendered:
1. Inpatient Hospital
2. Outpatient Hospital
3. Office
4. Home Health/Skilled Nursing Facility
5. All of the above
6. Other Specify:
Does your location have high-tech imaging equipment (PET, MRI, CT, Nuclear Medicine or Echocardiography? Yes No
List individual providers below:
Provider Name
BCBSNC
Provider #
(PPN)**
License
Number
Year of
Licensure
Specialty
**Individual Enrollment Applications are required for each provider to obtain an individual BCBSNC PPN.
*In order to ensure compliance with the Internal Revenue Service (IRS) regulations, we must have you tax identification information to
process your application. When submitting this enrollment application, please be sure to include a completed W9 containing the
billing entity information. Visit our external provider portal WWW.BCBSNC.COM for a copy of the W9 and other instructions for this
application.
Please Note: Enrollment does not establish you or your practice as an in-network BCBSNC provider. Separate processes are
required for credentialing and contracting. Please see the Enrollment Instructions document on the provider portal mentioned
above.
For additional information, please contact our Network Management Provider Services line at 1-800-777-1643 and select option 6.
Signature of Authorized Practice Representative:
Date: Contact Phone #:
click to sign
signature
click to edit
Additional Office Locations
Please note: Only locations where the practitioner works 2 or more days a week will display in our directory. Please
indicate for each location listed below.
Office location:
Street Address
Suite, Apt, etc.
City State
ZIP
County
Appointment Phone # Location Billing NPI
Will the practitioner work 2 or more days a week at this location? Yes No
Office location:
Street Address
Suite, Apt, etc.
City State
ZIP
County
Appointment Phone # Location Billing NPI
Will the practitioner work 2 or more days a week at this location? Yes No
Office location:
Street Address
Suite, Apt, etc.
City State
ZIP
County
Appointment Phone # Location Billing NPI
Will the practitioner work 2 or more days a week at this location? Yes No
Office location:
Street Address
Suite, Apt, etc.
City State
ZIP
County
Appointment Phone # Location Billing NPI
Will the practitioner work 2 or more days a week at this location? Yes No
Office location:
Street Address
Suite, Apt, etc.
City Sta
te
ZIP
County
Appointment Phone # Lo
cation Billing NPI
Will the practitioner work 2 or more days a week at this location? Yes No
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V510 Group Enrollment Application

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Completed 21 July 2020

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