Fillable form and provide to BCBSM upon request.: Group (Blue Cross Blue Shield of Michigan)

Fill Online, Printable, Fillable, Blank form and provide to BCBSM upon request.: Group (Blue Cross Blue Shield of Michigan) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

form and provide to BCBSM upon request.: Group (Blue Cross Blue Shield of Michigan)

On average this form takes 6 minutes to complete

The form and provide to BCBSM upon request.: Group (Blue Cross Blue Shield of Michigan) form is 2 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of Michigan forms online.

BROWSE BLUE CROSS BLUE SHIELD OF MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 2
Group Practice Agency Authorization and Acknowledgement Form
It is understood that Group, its representative, or delegate is responsible for having
each group member/individual practitioner execute the Group Practice Agency
Authorization and Acknowledgement Form. Group must retain copies of such executed
form and provide to BCBSM upon request.
I, as a member of ____________________________________________________
(name of group)
Identified by _________________________ __________________________________
(National Provider Identifier) (Group Provider Identification Number)
have aut
horized ___________________________________________________________________
(name of authorized group representative)
Check one or both: Applies to Traditional (Paragraph 1) Applies to BCN (Paragraph 2)
I authorize the Group Representative named above to act as my agent contracting with Blue Cross
Blue Shield of Michigan (BCBSM) and have given this agent the authority to sign the Blue Cross Blue
Shield Michigan Practitioner Traditional Participation Agreement (WP 7669 APR 14, WP 12273
NOV 11, WP 3356 APR 14, WP 11088 JAN 10, or WP 11089 JAN 10), the Blue Cross Blue
Shield of Michigan Clinical Licensed Master’s Social Worker Participation Agreement (WP
11438 JAN 11), the Blue Cross Blue Shield of Michigan Hearing Specialist Provider
Participation Agreement (WP 3376 APR 14), the Blue Cross Blue Shield of Michigan Athletic Trainer
Participation Agreement (WP 18432 JAN 21), the Blue Cross Blue Shield of Michigan Physician
Assistant Provider Participation Agreement (WP 16729 JAN 2018) or the Blue Cross Blue Shield of
Michigan Vision Specialist Provider Participation Agreement (WP 3392 JAN 14) on my behalf for
covered services I provide(d) to BCBSM members, consistent with the terms and conditions of the
Agreement. I agree that claims will be submitted only for covered services that are medically
necessary and that I personally perform or directly supervise. I also agree that this is a
continuing authorization and that information on claims’ forms submitted by group
representative have the same legal effect as if I had submitted it personally. I understand that I may
withdraw this authorization and leave the Group at any time by giving 60 days prior written notice to
the Group and to BCBSM. I agree to reimburse BCBSM for any losses that occur because of an
action on the part of group representatives that results in an overpayment to the Group for services
that I rendered.
WF 14267 AUG 20
Continued
Page 2 of 2
Group Practice Agency Authorization and Acknowledgement Form continued
I
authorize the Group representative named above to act as my agent to contract with Blue Care
Network of Michigan (BCN) and its subsidiary corporations, including but not limited to BCN
Service Company (BSC), to provide health care services under health benefit products
sponsored and/or administered by BCN, BSC or other BCN subsidiaries. By my signature
below, I affirm that I am familiar with the “BCN Affiliation Agreement(s)” signed on my behalf by
the Group Representative. I agree to be bound by all terms and conditions of such
Agreement(s), including applicable Provider Manuals and all amendments and modifications
thereto. This includes but is not limited to BCN Member hold harmless requirements; BCN
professional qualifications and credentialing standards; BCN fraud, waste and abuse policies;
government sponsored health benefit products; and BCN administrative programs. Among
these are policies related to quality management, medical management, network management,
Member education, Member grievance, claims processing and administration, and clinical and
nonclinical performance measurement and improvement. This Acknowledgement shall remain
in effect for the term of the “BCN Affiliation Agreement(s)” or until I disaffiliate from Group or
from BCN in accordance with termination provisions set forth in the “BCN Affiliation
Agreement(s)”.
1. _________________________________________
_______________________________
Provider’s Signature (required) Individual’s National Provider Identifier
_________________
________________________ _______________________________
Provider’s Name/Degree (print or type) License Number
2. _________________________________________
_______________________________
Provider’s Signature (required) Individual’s National Provider Identifier
_________________
________________________ _______________________________
Provider’s Name/Degree (print or type) License Number
3._________________________________________
_______________________________
Provider’s Signature (required) Individual’s National Provider Identifier
_________________
________________________ _______________________________
Provider’s Name/Degree (print or type) License Number
4. _________________________________________
_______________________________
Provider’s Signature (required) Individual’s National Provider Identifier
_________________
________________________ _______________________________
Provider’s Name/Degree (print or type) License Number
5. _________________________________________
_______________________________
Provider’s Signature (required) Individual’s National Provider Identifier
_________________
________________________ _______________________________
Provider’s Name/Degree (print or type) License Number
6. _________________________________________
_______________________________
Provider’s Signature (required) Individual’s National Provider Identifier
_________________
________________________ _______________________________
Provider’s Name/Degree (print or type) License Number
WF 14267 AUG 20
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

form and provide to BCBSM upon request.: Group (Blue Cross Blue Shield of Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document