Get Ma Bcbs Mpc_120915-5w 2020-2025

This guide provides clear, step-by-step instructions for filling out the MA BCBS MPC_120915-5W form online. By following these guidelines, users can ensure a smooth application process and timely review of their credentials.

Follow the steps to complete your application online:

1. Click the ‘Get Form’ button to access the MA BCBS MPC_120915-5W and open it in the online editor.
2. Begin by identifying your provider type. Check the box for either Certified Nurse Midwife (CNM) or Certified Nurse Practitioner (CNP) as applicable.
3. Fill in your personal information in the 'Practitioner information' section, including your first name, last name, National Provider Identifier (NPI), social security number, date of birth, and any relevant license numbers.
4. Provide your practice location information. Specify the employment or start date at your practice, and indicate whether this will be your primary or secondary practice.
5. List the main practice location details (name, tax ID number, address, contact information) and include any additional practice locations if applicable.
6. Complete the 'Billing address' section to specify where payments should be sent. This can be the main practice location or another address.
7. In the 'Contract recipient' section, input the email of the practitioner who will receive the contract for signature. Ensure to check for the email in spam folders.
8. Indicate your practitioner availability status, noting whether you are accepting new patients and if you offer telehealth services.
9. For Certified Nurse Practitioners only, specify whether you will provide primary or specialty care services and select relevant specialties.
10. Attach a copy of your current certification and, if required, a signed IRS Form W-9.
11. Review all completed sections for accuracy, and once satisfied, submit the form online and ensure to keep a copy for your records.

Complete your MA BCBS MPC_120915-5W application online today for seamless credentialing!