Individual Signature Document
A nonprofit corporation and independent licensee
of the Blue Cross and Blue Shield Association
WF 14551 JUL 18
Your signature below establishes your commitment to be legally bound by the
terms and conditions of the Practitioner Affiliation Agreement(s) you check below.
Michigan Professional License Number
Individual Name Individual NPI
Provider Enrollment and Data Management
Blue Cross Blue Shield of
Fax to 866-900-0250
Please return this
Signature Document to:
DANIEL J. LOEPP
President and CEO
Blue Cross Blue Shield of Michigan
Managed care network affiliations do not become active until the credentialing process has
been successfully completed and the relevant contracts have been signed.
Until you are formally affiliated with these networks, you are regarded as an out of network
practitioner and out of network claims sanctions may apply.
BCBSM Licensed Master Social Worker Participation Agreement
BCBSM Clinical Licensed Master's Social Worker Traditional Participation Agreement
(WP 11438 JAN 11) incorporated by reference. The effective date of your participation in
Traditional will be as of the date of your signature below, provided you meet all applicable
BCBSM TRUST (also known as TRUST PPO) Network Practitioner Affiliation Agreement
(WP 7637 JUN 16) incorporated by reference.
BCBSM Medicare Advantage Provider Agreement (WP 10380 SEP 15) and
Practitioner Attachment (CF 10381 JUL 08) incorporated by reference.
BCBSM Mental Health and Substance Abuse Managed Care Network Participation
Agreement (WP 0565 JAN 16) incorporated by reference
The TRUST Network Practitioner Affiliation Agreement, the BCBSM Medicare Advantage
Provider Agreement and the Mental Health and Substance Abuse Managed Care
Network Participation Agreement will become effective once you have successfully completed
the credentialing process. You will receive a letter notifying you of the outcome
of the credentialing process and the effective date of your affiliation with each, applicable
The Signatures on the letter you receive will serve as BCBSM's countersignature
on the Agreement, thereby creating a final contract between you and BCBSM. You will then be
formally affiliated with the applicable network and be regarded as an in network practitioner.
Licensed Master Social Worker