Get Mi Bcbs E-referral Application Form 2006

Filling out the MI BCBS E-Referral Application Form online is an important step for providers seeking access to electronic referral services. This guide will provide a comprehensive, step-by-step approach to completing each section of the form accurately.

Follow the steps to complete your e-referral application seamlessly.

1. Press the ‘Get Form’ button to access the MI BCBS E-Referral Application Form and open it in your editor.
2. Begin by entering the provider or facility name in the designated field, ensuring it accurately reflects your practice.
3. Next, select the appropriate specialty or department from the dropdown menu that corresponds to your practice.
4. Fill in the complete address, including city, state, and zip code, to ensure accurate processing.
5. Provide a primary contact person's name and their contact information, including telephone number and fax number, for follow-up queries.
6. In the email section, supply the contact email address for any correspondence related to the application.
7. Enter the current web-DENIS ID specifically for your physician group in the appropriate field for identification.
8. List the provider codes for all physicians or facilities requesting e-referral access to ensure correct enrollment.
9. Sign and date the authorization section at the bottom of the form, asserting that the information provided is accurate.
10. Print or type your name and title in the designated area for the signer to identify yourself formally.
11. Complete the tax ID number section, as this is a required field for processing your application.
12. Finally, fax both pages of the completed application to the appropriate BCN Provider Affairs office listed for your region.

Complete your MI BCBS E-Referral Application Form online today to streamline your referral processes.