Get Bcn Mcg Affiliation Form

Completing the Bcn Mcg Affiliation Form online is an essential step for providers in the Blue Care Network. This guide will walk you through the process of filling out the form accurately and efficiently, ensuring that all necessary information is included.

Follow the steps to fill out the Bcn Mcg Affiliation Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Provide your Type 1 NPI and Type 2 NPI numbers. These are unique identifiers needed for your practice.
3. Enter your Tax Identification Number. This number is crucial for processing and tracking payments.
4. Fill in your State License Number, which verifies your authority to practice in your region.
5. Indicate your PCP status change by selecting ‘Yes’ or ‘No.’ This determines whether you are changing your role within the network.
6. If applicable, indicate if you perform home visits, are a hospitalist, or have a private practice location outside of hospitals by selecting ‘Yes’ or ‘No.’
7. Complete the changes to BCN networks and MCG affiliations based on your status change. Additional details may be required depending on the type of change.
8. For specialists adding MCG affiliation or changing from PCP to specialist or vice versa, follow the specific instructions provided in the MCG Endorsement section.
9. If terminating your affiliation with MCG, specify the name and number, along with the requested end date if it exceeds 60 days.
10. Complete the Signature and Contact section and verify that the information provided is accurate.
11. Provide contact information for someone who can answer questions regarding this form.
12. After confirming all details are accurate, save changes, download your completed form, and proceed to print or share it as needed.

Ensure your affiliation documentation is accurate and complete by filling out the Bcn Mcg Affiliation Form online today.