Fillable e-referral Request for Group ID Changes FAX COVER (Blue Cross Blue Shield of Michigan)

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e-referral Request for Group ID Changes FAX COVER (Blue Cross Blue Shield of Michigan)

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The e-referral Request for Group ID Changes FAX COVER (Blue Cross Blue Shield of Michigan) form is 2 pages long and contains:

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e-referral Request for
Group ID Changes
FAX COVER PAGE
Fax To:
From (office):
Date:
SEP 19
• 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:
Section 1.
If NPI(s) should be added to e-referral, list NPI(s) below.
Provider or Group Name
NPI Number
10-digit NPI Number
10-digit NPI Number
10-digit NPI Number
If NPI(s) should be removed from e-referral, list NPI(s) below.
Provider or Group Name
NPI Number
10-digit NPI Number
Date
Type Name of the Authorized Signer
Title of Authorized Individual
Signature of Provider/Facility Authorized Individual
Handwritten Signature Only
For questions call 1-877-258-3932 Send Fax to 1-800-495-0812
WF12798 JUL 20
© Blue Cross Blue Shield of Michigan and Blue Care Network are a nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Office/Practice/Group Name: (where users are located)
Street Address and Suite Number (address where users are located)
Office Contact Person
City State Zip Code
Contact Person's Telephone
Extension
10-digit NPI Number
10-digit NPI Number
REMOVE NPI(s)
ADD NPI(s)
10-digit NPI Number
e-referral Request for Group ID Changes
Please complete electronically
Please note: The request to add/delete providers will affect access at the practice level, not individual users
Section 2.
Section 3.
Section 4.
10-digit NPI Number
10-digit NPI Number
By signing below, I represent and warrant that I have been granted full legal authority, by corporate resolution,
appropriate delegated signature authority, or as permitted by a signature authorization policy, to enter into and bind
the provider and/or facility group to contracts and agreements and, intending to be legally bound, have executed this
agreement on the date listed above.
Authorization
Contact person company issued email address
Please provide a Provider Secured Services ID
that currently has access to e-referral ID:
User ID
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e-referral Request for Group ID Changes FAX COVER (Blue Cross Blue Shield of Michigan)

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Completed 10 February 2021

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