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

Filling out the New Allied Provider Enrollment Form accurately is essential for your enrollment with Blue Cross Blue Shield of Michigan. This guide provides a detailed walkthrough of each section of the form to ensure you complete it correctly and efficiently online.

Follow the steps to complete the enrollment form effectively.

1. Press the ‘Get Form’ button to access the form online in an editable format.
2. Begin with Section 1: Demographic data. Here, provide your provider name, the type of provider you are, and your primary address. Make sure to indicate if you are open for business and include the date if applicable.
3. Proceed to Section 2: EIN/Tax information. Enter your EIN/Tax ID number and the name associated with it, as shown on your IRS documentation. Specify whether your organization is tax-exempt.
4. In Section 3: Requested networks, select the networks you are applying to and indicate whether you wish to enroll as participating or nonparticipating. Provide the requested effective date.
5. Move to Section 4: Professional IDs/Required documentation. Fill in your professional IDs such as ambulance license or CLIA number and attach necessary documentation as indicated.
6. If applicable, complete Section 4A for Urgent Care Center information, including the name and license details of the UCC Medical Director.
7. In Section 6: Provider secured services, fill in the name and contact details for the Web Access Administrator. Indicate if they currently use Provider Secured Services and provide necessary information for additional users.
8. Sign Section 9: Application signature. Print your name, sign, and date the application to certify that all provided information is accurate.
9. After reviewing your entries for accuracy, save the changes to your completed form. You can then print or share the form as needed.

Complete your documents online today to ensure a smooth enrollment process.