Get Ok Bcbs Solo Provider Enrollment Form 2020-2025

Completing the OK BCBS Solo Provider Enrollment Form online is a straightforward process that requires attention to detail. This guide will provide you with a step-by-step approach to ensure all necessary information is accurately filled out, facilitating a smooth enrollment process.

Follow the steps to successfully complete your enrollment form.

1. Press the ‘Get Form’ button to access the OK BCBS Solo Provider Enrollment Form and open it in your document handler.
2. Begin with the submitter information. Fill in your first name, middle initial, last name, suffix (if applicable), email address, telephone number, and job title or position.
3. Select your network participation by checking either 'Participate In-Network' or 'Participate Out-of-Network.' Also, indicate if you are completing the form for a contract as a solo provider.
4. In the practitioner information section, specify if the provider is currently in a residency program by checking 'Yes' or 'No.' Fill in the primary provider type, specialty, sub-specialty, CAQH/HSC number, license number, and tax identification number.
5. Complete the personal information section with your first name, middle initial, job title, last name, suffix, date of birth, and gender.
6. Provide additional personal and practitioner information. Indicate your type, specialty, sub-specialty, whether you will join a Medicare network, your Medicare number, DEA number, hospital admitting privileges, admitting hospital type, ambulatory surgery center privileges, languages spoken, and cultural competency training completion status.
7. Fill out the office physical location details including location name, office contact name, and contact numbers. Complete the address fields and appointment phone number, and specify if language line services are offered.
8. Indicate your servicing practice locations by checking applicable options such as hospice visits, patient’s home visits, nursing home visits, and skilled nursing facility visits.
9. Complete the hours of operation section. Ensure you specify the time zone and provide opening and closing times for each day of the week.
10. Answer the Americans with Disabilities Act section regarding compliance with ADA standards in various aspects of the office.
11. Complete the treating categories section by indicating whether the provider treats specific groups by checking 'Yes' or 'No' for each category.
12. Fill out the associations section, including names and tax identification numbers for any relevant organizations you are affiliated with.
13. If necessary, provide a different correspondence address, billing address, and credentialing address; otherwise, confirm they are the same as the office physical location.
14. Complete the administrative contact details and include any relevant comments.
15. In the practice information section about telemedicine and lab services, indicate whether these services are rendered and provide necessary details.
16. Answer the questionnaire regarding your previous participation with BCBSOK, malpractice insurance, any restrictions on coverage, any actions by peer review organizations, and explain any gaps in your professional career.
17. Attach required documents as specified in the attachments section.
18. Finalize by filling out the attestation section with your name, title, tax identification number, and today’s date.
19. After completing the form, ensure all information is correct. Save your changes, download, print, or share the completed form as necessary.

Ensure your enrollment is completed successfully by filling out the OK BCBS Solo Provider Enrollment Form online today.