Get New Allied Practitioner Enrollment Form - Blue Cross Blue Shield Of ...

Filling out the New Allied Practitioner Enrollment Form is a vital step for healthcare providers looking to enroll with Blue Cross Blue Shield. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently in an online format.

Follow the steps to complete your enrollment form online.

1. Click the ‘Get Form’ button to access the form and prepare to fill it out in your browser.
2. Enter all required information accurately in Section 1: Demographic Data, making sure to complete fields such as your first name, last name, and type of provider.
3. Continue to Section 2: Employer ID number/Tax information, ensuring your Social Security number or EIN/Tax ID number are entered correctly.
4. In Section 3: Request networks, indicate the networks you wish to apply to and provide any necessary signature documents if required.
5. Proceed to Section 4: Address Data, input your primary address, primary telephone number, and any payment or mailing addresses.
6. Fill out Section 5: Additional practice locations, adding any additional addresses where healthcare services will be rendered.
7. In Section 6: Provider Secured Services, provide information if you want to access online services and list any required personnel.
8. Finally, complete Section 7: Application signature by certifying the accuracy of your information and signing the form.
9. Once all sections are filled, you can save any changes, download or print the document, or share it as needed for submission.

Ensure your healthcare practice is properly enrolled by completing the New Allied Practitioner Enrollment Form online today.