Get Information Completed And Returned To Us By Mail Or Fax

This guide is designed to support users in completing the Information Completed And Returned To Us By Mail Or Fax form accurately and efficiently. The information provided is crucial for the assignment of a provider number with Blue Cross Blue Shield of Alabama.

Follow the steps to successfully fill out your form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out your personal details in the 'Practitioner Information' section, including your Social Security Number, name, and contact information. Ensure that all required fields marked with an asterisk are completed.
3. In the 'Practice Information' section, provide details about your legal practice name, Tax ID, and other relevant office details. Confirm whether you accept Medicare patients and indicate your office's telephone and fax numbers.
4. Complete the 'Covering Physicians' and 'Physician Extenders' sections by listing any additional medical professionals associated with your practice.
5. Fill out the 'Conflict of Interest' section by disclosing any relevant business interests that may exist.
6. Enter all necessary medical and professional licenses in the 'State Medical License,' 'State Drug License,' and 'Federal DEA License' sections. Be sure to provide the issue and expiration dates for each certificate.
7. Provide details about your professional liability insurance in the 'Professional Liability' section. List your current and any previous carriers, along with policy numbers and coverage amounts.
8. Fill in the 'Education' and 'Training' sections with information about your academic background, internships, residencies, and fellowships.
9. Complete the 'Board Certification' section by providing any relevant board certification details.
10. Fill out the 'Professional Practice History' section detailing your work experience from graduate school to the present.
11. List your current and past hospital admitting privileges in the relevant sections.
12. Review and answer the 'Questionnaire' ensuring that each question is answered honestly and completely.
13. Finally, sign the 'Provider Authorization' section to confirm the accuracy of your details and to authorize information verification.
14. Once all sections are complete, you can save your changes, download, print, or share the form as needed.

Complete your documents online to streamline the application process.