Get Csxqhcomql Form

Filling out the Csxqhcomql Form online is an essential step for providers looking to maintain or update their information with Anthem Blue Cross and Blue Shield. This guide provides clear and detailed instructions to navigate each section of the form effectively.

Follow the steps to complete the Csxqhcomql Form online successfully.

1. Press the ‘Get Form’ button to obtain the Csxqhcomql Form and open it in your preferred online document editor.
2. In Section A, provide the general information requested, including your Practice Tax ID Number, Anthem 12-Digit Physician Identification Number, and the name of your group or practice. Specify whether it's a solo or group practice.
3. In Section B, indicate the reason for submitting the form. Select one Tax ID per PMF and provide the effective date of any changes. Select from options such as adding or deleting a provider, changing the practice name, or updating contact information.
4. Move to Section C for Provider Information. Complete all required fields marked with an asterisk, including the provider's first name, last name, primary specialty, title, and other identifiers like the NPI and date of birth.
5. Section D requires you to fill out the practice address, including city, state, and zip code. If the remit address differs from this, provide that information as well.
6. If there is an address change, use Section E to specify the new address details. Include any updated contact information.
7. In Section F, list any additional office locations, including the required remit address for each site. Make sure to note if these locations will be listed on Anthem's directory.
8. Section G is specifically for covering physicians, where you can provide details on PCPs and OB/GYNs in HMO networks.
9. Add any relevant comments in Section H that may assist with the processing of the form.
10. Finally, in Section I, ensure to provide the provider office contact's details and verify the accuracy of the information provided. Save all changes, and proceed to download, print, or share the completed form.

Complete the Csxqhcomql Form online with confidence and ensure your provider status remains up to date.