Get Ma Bcbs Mpc_120915-2a 2019-2025

Filling out the MA BCBS MPC_120915-2A form online is a crucial step in the contracting process with Blue Cross Blue Shield of Massachusetts. This guide provides detailed instructions to help you navigate each section of the form efficiently.

Follow the steps to complete your form accurately.

1. Press the ‘Get Form’ button to access the MA BCBS MPC_120915-2A form and open it in your preferred editing tool.
2. Begin by providing your practitioner information. Fill in fields such as your first name, last name, National Provider Identifier (NPI), social security number, date of birth, Massachusetts license number, and DEA certificate number if applicable.
3. Enter your practice location information. Specify your main practice location, including the legal name of your practice, tax ID number, and address. It is essential to ensure that all details are correct to avoid delays.
4. If applicable, fill in information for any additional practice locations where you will be providing services. Include the site name, street address, and phone number for scheduling appointments.
5. Complete the billing address section, indicating whether it is the same as your main practice location or entering a different address.
6. Provide the necessary details for contract recipient and welcome letter recipient, which includes the email addresses of the designated individuals. Ensure you add BlueCrossContractOps@bcbsma.com as a trusted sender.
7. Indicate your practitioner availability status and the services you offer, such as accepting new patients or providing telehealth services.
8. Continue filling out the collaborating/supervising arrangement section by listing your collaborating physician's details. This is necessary for compliance with contract requirements.
9. Complete the sections related to hospital affiliation and admitting privileges if applicable to your practice.
10. Select the Blue Cross products you wish to participate in and read through the signature waiver section, making your choice accordingly.
11. Review and sign the release and representations section, ensuring all information provided is accurate.
12. Once completed and signed, save your changes, and consider downloading or printing a copy of the form for your records. Finally, fax the completed application to 617-246-4227.

Complete your MA BCBS MPC_120915-2A form online today to ensure a smooth application process.