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Get MA BCBS MPC_121515-2T 2019

Use this form to notify Blue Cross* of a change to a contracted practitioner's practice status, etc. as listed below. Please retain a copy of this completed form for your files. If needed, a new contract will be mailed for you to complete and return. You cannot provide covered services and be reimbursed as a participating provider in any new practice or new Product until you are notified by Blue Cross that the new contract is in effect. Check all that apply:.

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