Fillable form through the RBCE issue log, and complete (Blue Cross Blue Shield of Michigan)

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form through the RBCE issue log, and complete (Blue Cross Blue Shield of Michigan)

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WF 10905 JUN 20
PGIP PO / OSC / RBCE / MCG Access Application
Physician Organization (complete sections 1, 2, 5 and 6)
Organized System of Care (complete sections 1, 2, 5 and 6)
Risk Bearing Contracted Entity (complete sections 2, 3, and 6)
Medical Care Group (complete sections 2, 4, and 6)
No handwritten forms are accepted, complete electronically.
Section 1
Physician Organization or Organized System of Care Name
Street Address and Suite Number (address where users are located)
Primary contact person
City
State ZIP Code
Primary contact person’s telephone and extension
Tax ID
Contact Person’s company issued Email address
Section 2
Type the name(s), phone number(s), and if applicable the assigned Provider Portal Access ID(s) of the individual(s) requiring access. All individuals using Provider
Portal Access must be included below to receive their own user Provider Portal Access ID. ID(s) may not be shared among the office staff.
Note: If no Access ID exists, please leave the “Current Provider Portal Access ID” space blank. If user has had prior Access ID, please include it in the column.
Name (type in full legal
name for each user)
Email Address of
individual
User’s telephone #
and extension
Current
Provider
Portal Access
ID
PO
OSC
HEB
RBCE
Select
One*
MCG
Select
One*
John Doe
jdoe@xyz.com
111-222-3333
F000000
R
RW
R RW
*R = Read Only *RW = Read & Write Access If additional space is needed, attach an additional page.
Section 3
Risk Bearing Contracted Entity Name Contact Person
Street Address and Suite Number Contact Person’s Phone Number and Extension
City
State
ZIP Code
Contact Person’s company issued email address
RBCE ID
Is access to the RBCE Self Service Tool Needed? Yes No
Note: Access to the RBCE Collaboration site will automatically be granted to all contacts in a RBCE when this form is completed
Note: If adding a contact to both a PO and OSC, you must add the contact to
both the PO and OSC separately in the PGIP PA tool. If adding PGIP access AND
RBCE/MCG, please add contact through PGIP PA first prior to faxing MCG/RBCE
information in section 2, 3, 4 and 6.
If adding just collaboration site access for RBCE contact, please submit this
form through the RBCE issue log, and complete Section 2, 3 and 6 below. If
adding HEB access for a PO or OSC, additionally complete Section 5 below.
Section 4
Medical Care Group Name Contact Person
Street Address and Suite Number Contact Person’s Phone Number and Extension
City
State
ZIP Code Contact Person’s company issued email address
MCG ID
Is access to the MCG Self Service Tool Needed?
Yes No
Note: There is currently no MCG Collaboration site
Section 5
For Health e-Blue access, fill out the section below.
Please note - Requesting Health e-Blue will add additional processing time.
BCN HMO and/or BCBSM Physicians For individual providers, enter Michigan state license number(s)
BCN Physician Organization Enter the BCN IH Code(s)
BCBSM Physician Organization Name/Identifier(s):
Section 6 Mandatory
Authorization for use & access, I hereby state the information provided on this application is correct.
___________________________________________
Provider authorized signature (Handwritten Only)
Do Not Use a Signature Stamp on the Line Above or Application will be Rejected
___________________________________________
Type or print name of the authorized s
igner
Signer’s Title
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
group to contracts and agreements and intending to be legally bound have executed this agreement on the date above.
1. I understand that by signing above I have the 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)
2. I agree to use the data obtained only in the manner specified by Blue Cross Blue Shield of Michigan (BCBSM) applicable agreements.
3. I agree to certify any data obtained or submitted shall be for services performed by or under direct supervision of the Provider named
above.
4. I agree to assure the information obtained or transmitted shall be confidential and used only for the purpose of transacting BCBSM
business.
Instructions for Submitting Application
If access is for a PO or OSC, after completing the application listing the user’s names, do the following:
1. Sca
n the application and save it.
2. PGIP
P
ri
mary contact must sign into the PGIP PA tool and add the contact(s) under “Edit OSC” or “Edit PO” wizard.
3. Primary contact must attach the PDF application by clicking the add document in the transaction.
4. Once the transaction has been completed it will take a few days for our security team to process the application.
Note: If you have issues adding the contact(s) through the PGIP PA tool, please enter a new issue under the “Add or Drop user access to the
PGIP Collaboration site” in the Issue log found on our external Share Point collaboration site.
If access is for a RBCE or MCG, after completing the application do the following:
1. Fax the completed 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 Blue
Shield Association.
WF 10905 JUN 20
Date
Note: HEB access can only be requested with this application for Physician Organizations and Organized Systems of Care
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form through the RBCE issue log, and complete (Blue Cross Blue Shield of Michigan)

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Completed 10 February 2021

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