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Get CA Blue Shield ICF-01 2018-2024

Lifornia (Blue Shield) and/or Blue Shield of California Promise Health Plan (Blue Shield Promise) to add, change, or remove information on an established practitioner record. Blue Shield and/or Blue Shield Promise will confirm that the request has been processed. Instructions Identify the practitioner requiring changes by populating the Practitioner Name, Tax Identification Number (TIN), and National Provider Identifier (NPI) fields. Complete all applicable fields that require changes. Attach al.

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