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  • Bcbsmnincand Affiliates Individual Practitioner Additiontermination Form

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This form when adding or terminating an individual practitioner to your clinic. If initial credentialing or re-credentialing is required, the Credentialing Department will contact you. Practitioners may not see patients until the credentialing process has been completed. If you have any questions, contact Provider Service at (651) 662-5200 or 1-800-262-0820. Date of Request: Individual Practitioner Information Last Name: First Name: Previous Names: Sex: Suffix: Mid Init: Male Female Tit.

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All claims must be resolved with 365 calendar days from the date of service or discharge date. This applies to capitated and fee-for-service claims.

Contact your practice management or hospital information system for instructions on how to receive ERAs from Blue Cross Complete under Payer ID 32002 and the ECHO Payer ID 58379.

Provider payer ID is 00562.

Your Payer Name is Empire BlueCross BlueShield HealthPlus. Your Payer ID is 27514. Note: If you use a billing company or clearinghouse for your EDI transmissions, please work with them on which payer ID they want you to use.

Blue Cross and Blue Shield of Michigan, 600 E Lafayette Blvd, Detroit, MI, Insurance Group - MapQuest.

For questions about ID cards, benefits, claims or other issues: Call the number on the back of your member ID card or 313-225-9000.

For questions about ID cards, benefits, claims or other issues: Call the number on the back of your member ID card or 313-225-9000.

Florida Blue Medicare has a unique Availity®1 payer ID, Florida Blue Medicare (FBM01).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232