Get New Mental Health Practitioner Enrollment Form Wf 10575 Apr 12

Filling out the New Mental Health Practitioner Enrollment Form WF 10575 APR 12 is an essential step for practitioners seeking affiliation with Blue Cross Blue Shield of Michigan and Blue Care Network. This guide provides detailed, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the enrollment form online.

1. Click the ‘Get Form’ button to access the New Mental Health Practitioner Enrollment Form WF 10575 APR 12 online.
2. Begin by entering your personal information in Section 1, Demographic Data. Complete all required fields marked with an asterisk (*), including your first name, last name, degree, date of birth, and gender. Ensure accuracy as this information is critical for your application.
3. Proceed to Section 2, Employer ID Number/Tax Information. Fill in your Social Security Number and indicate whether your Employer Identification Number (EIN) or Tax ID number is the same as your SSN. If applicable, complete the additional required fields.
4. In Section 3, Specialty, indicate your specialty and whether you are board certified if applicable. This information helps categorize your practice.
5. Move on to Section 4, Requested Networks. Check the networks you are applying to participate in, and provide a requested effective date if necessary.
6. Fill out Section 5, Address Data. Enter your primary office address and contact information, ensuring it reflects where you provide health care services. Additionally, supply any alternate addresses if different from your primary address.
7. In Section 6, Additional Practice Locations, list any other locations where you offer services, including relevant contact details for each site.
8. Complete Section 7, Provider Secured Services – Web-DENIS. Provide details for the Web Access Administrator. If they do not have an existing login ID, complete the respective fields for new users.
9. In Section 8, Internet Claims Tool, check the necessary boxes to sign up for electronic claims submission, ensuring you provide your browser and system information if applicable.
10. Finally, fill out Section 9, Application Signature. Print your name, sign, and date the form to certify the information you have provided is true and complete.
11. Save your completed form, download or print it, and submit it through the desired method as instructed.

Complete your New Mental Health Practitioner Enrollment Form online now and ensure your application is processed efficiently.