Get Pdf Provider Enrollment Application For Blue Shield Of North Carolina

Filling out the Pdf Provider Enrollment Application for Blue Shield of North Carolina is an essential step for healthcare providers seeking enrollment. This guide provides clear, step-by-step instructions to assist users in completing the application accurately and efficiently.

Follow the steps to successfully complete your application online.

1. Click the ‘Get Form’ button to obtain the document and open it in your preferred reader.
2. Begin by entering your name in the designated fields, including your last name, first name, and mid-initial as applicable.
3. Provide your County number and County name to ensure accurate location information.
4. Indicate your degree by selecting the appropriate option from the drop-down menu.
5. Fill in your Social Security Number, taking care to ensure it is accurate.
6. Select your specialty and indicate if you are a primary care provider or a specialist.
7. Enter your National Provider Identifier (NPI) number in the corresponding field.
8. Provide your Taxonomy Code and Description to classify your specialty accurately.
9. Input your license number and Medicare Provider number if applicable, ensuring you attach a copy of your most recent license renewal slip.
10. Choose whether you are submitting a Non Participating Enrollment Request or a Participation Contract Request.
11. Enter your appointment phone number as well as the actual office location details including street address, city, state, zip code, and county.
12. If you operate from additional locations, indicate this in Section 2 and provide the relevant details.
13. Answer additional questions regarding previous BCBSNC provider numbers and whether you currently file electronically with Blue Cross Blue Shield of North Carolina.
14. Indicate the places where services will be rendered, selecting from the provided options.
15. Complete your form by signing it as the authorized representative and including the date and contact phone number.
16. Once all sections are completed, save any changes you made, and download the application. You may then print or share it as needed.

Ensure your application is completed correctly by following these steps online.