Get Excellus Bcbs Application For Non-physician Health Care Practitioner 2020
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How to fill out the Excellus BCBS Application For Non-Physician Health Care Practitioner online
Completing the Excellus BCBS Application For Non-Physician Health Care Practitioner online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the application to ensure that you provide all necessary information accurately.
Follow the steps to fill out the application form effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by specifying the purpose of the application. Indicate whether this is a first-time application, demographic change, or sponsor change, and check the appropriate box.
- Fill in your personal details including your last name, first name, middle initial, individual NPI number, date of birth, gender, taxonomy code (required), license number and state, Medicare number, languages spoken, DEA certificate number and state, social security number (required), and Medicaid number (required). Make sure all mandatory fields are completed.
- Provide details about your collaborating physician, which includes their name, specialty, and NPI number.
- List your group information by entering the group NPI number, group name, and billing tax ID number.
- Enter your primary office address, ensuring to include street address, city, state, zip code, and phone number (required). Specify if the office is handicap accessible.
- If applicable, provide additional office addresses following the same format as the primary office, indicating accessibility options as necessary.
- Fill in the correspondence, remittance, and medical records addresses, noting that each address must be a valid U.S. Postal Service mailing address.
- Review the applicant attestation section carefully, ensuring that the information is accurate, and include your name (signature) and date.
- Complete the collaborating physician attestation, including their printed name, signature, and date. Provide the office contact name, phone, and email.
- Finally, ensure that all required documents, such as diplomas, licenses, malpractice insurance, and W-9 forms, are attached before submission.
Start filling out the Excellus BCBS Application for Non-Physician Health Care Practitioner online today!
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Excellus BCBS is a regional member of the broader Blue Cross Blue Shield network. While both share the same foundational services and values, Excellus BCBS operates specifically in New York. Therefore, when considering the Excellus BCBS Application for Non-Physician Health Care Practitioner, make sure to familiarize yourself with the specific requirements and local guidelines relevant to your practice.
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